|FAMILY MEDICINE EDUCATION
|Year : 2015 | Volume
| Issue : 2 | Page : 168-173
Training medical students in general practice: a qualitative study among general practitioner trainers in Sri Lanka
R.P.J.C. Ramanayake, A.H.W. De Silva, DP Perera, R.D.N. Sumanasekera, L.A.C.L. Athukorala, K.A.T. Fernando
Department of Family Medicine, Faculty of Medicine, University of Kelaniya, Sri Lanka
|Date of Web Publication||8-Apr-2015|
Department of Family Medicine, Faculty of Medicine, University of Kelaniya
Source of Support: None, Conflict of Interest: None
Introduction: Worldwide Family Medicine has gained an important place in the undergraduate medical curriculum over the last few decades and general practices have become training centers for students. Exposure to patients early in the disease process, out patient management of common problems, follow up of chronic diseases and psychosocial aspects of health and disease are educational advantages of community based training but such training could have varying impact on patients, students and trainers. This study explored the views of General Practitioner (GP) trainers on their experience in training students. Methodology: This qualitative study was conducted among GP trainers of the faculty of medicine, University of Kelaniya, Sri Lanka, to explore their experience on wide range of issues related to their role as GP trainers. The interviews were recorded and transcribed verbatim. Themes expressed were identified. Results: Altruistic reasons, self-satisfaction, self-esteem and opportunity to improve their knowledge were the motivations for their involvement in teaching. Teachers were confident of their clinical and teaching skills. They perceived that patients were willing participants of the process and benefited from it. There was a positive impact on consultation dynamics. Time pressure was the major problem and ideal number of trainees per session was two. They were willing to attend teacher training workshops to update their knowledge. Conclusions: GP trainers driven by altruistic reasons were willing participants of student training process. The perceived advantages of involvement of teaching for trainers and patients were an encouragement for potential trainers. University should organize training sessions for trainers which will boost their knowledge, confidence and teaching skills which will eventually benefit students.
Keywords: General pratictioners, training, undergraduates, medical education
|How to cite this article:|
Ramanayake R, De Silva A, Perera D P, Sumanasekera R, Athukorala L, Fernando K. Training medical students in general practice: a qualitative study among general practitioner trainers in Sri Lanka. J Family Med Prim Care 2015;4:168-73
|How to cite this URL:|
Ramanayake R, De Silva A, Perera D P, Sumanasekera R, Athukorala L, Fernando K. Training medical students in general practice: a qualitative study among general practitioner trainers in Sri Lanka. J Family Med Prim Care [serial online] 2015 [cited 2019 May 27];4:168-73. Available from: http://www.jfmpc.com/text.asp?2015/4/2/168/154623
| Introduction|| |
Worldwide there has been a revolution in the delivery of medical education in the last two decades with more and more emphasis on training undergraduates in the community based primary care settings.  The general medical council's report in 1993  recommended that the greater proportion of undergraduate training should take place in general practice and it was re-emphasized in the 2002 version,  which stated that clinical education must reflect the changing patterns of health care and provide experience in a variety of environments, including hospitals, general practices and community medical services. In fact, there is a worldwide consensus that medical education should have more relevance to the health needs of the community. 
In the declaration of Alma Ata,  it was proposed that teaching health care professionals in the community, away from tertiary care centers, would result in more students electing to work in primary care and in rural and remote areas. This idea was echoed by some general practitioner (GP) trainers in UK as well. 
The educational advantages of community based training have been well-documented: Contact with patients in the early stage of illness, opportunity to gain experience in common conditions, psychosocial problems, progression of illness, follow-up of chronic disease, and communication skills. , Another distinct advantage is the high level of supervision students receive compared to training in a hospital. 
Training undergraduates in ambulatory care settings could have implications to the patients, GP trainers and students. Longer waiting time and consultation time, privacy and confidentiality issues are some of problems encountered by patients. , Impact on doctor patient relationship, reduced number of patients and income, time, and space are the issues faced by trainers. , Distance, travelling time, and expenses are the problems encountered by the students. 
A duty to teach medical students and junior doctors has been identified as a professional obligation in a number of clinical codes from the time of Hippocrates to the present. ,
In western countries GPs have been involved in undergraduate training for a long period and the number of training sessions has increased considerably over the past few decades. ,,,,
In Sri Lanka, traditionally, major part of undergraduate training takes place in teaching hospitals and family medicine is a relatively new discipline in Sri Lankan medical schools and there are only a small number of GP trainers in the country. Even at present, there are a few medical schools, which have not included family medicine into their curricula. At the faculty of medicine, University of Kelaniya, 4 th year students undergo 4 weeks of training in family medicine. They are exposed to a number of ambulatory care settings during the attachment, which includes training in university family practice, visits to the outpatient department of the nearby teaching hospital and general practices in the community. There are 20 general practices in the community, which train undergraduates. These general practices are fee levying, solo practices and GPs in these practices have post graduate qualification in family medicine and have been training undergraduates for >10 years. The learning objectives are sent to them at the beginning of the academic year and whenever a group of students start visiting these practices. These GP trainers are paid an honorarium by the university for training undergraduates in their practices. Two to three students are allocated to a general practice and they have three training sessions of 3-4 h duration with the GP trainer in the practice. Some of the GPs train students from other medical faculties as well. Although the duration of training of an undergraduate is 5 years in all the medical faculties in Sri Lanka, there is no uniformity in the family medicine curricula. Therefore, these GP trainers come across students of different levels of the undergraduate training.
Most of the reported studies on training undergraduates in community setups have been from the western world and there is a real dearth of information in this regard from the south Asian region. One reason may be that unlike in the developed countries community-based training has not taken root in this part of the world. This study fills a vacuum by exploring experiences of GP trainers on a wide range of issues, which will be of benefit to medical faculties, medical educationists and GP trainers.
| Methodology|| |
This was a qualitative study. A total of 11 GP trainers were purposively selected to achieve the maximum range of views and experiences of teachers. The sample included practitioners from urban and semi urban areas, small and large practices, both genders and mix of senior and young doctors. Teachers selected were contacted initially by the investigators to inform them about the study and to seek their collaboration.
A semi-structured interview schedule was designed to cover different aspects of training students, which included the positive and negative effects of training undergraduates, effect of teaching on consultation dynamics, delivery of service and practice organization, confidence in clinical and teaching skills and their expectations from the university. These issues were selected from the researchers' experience, literature review and discussion with other GP trainers and medical educationists.
A preintern medical officer who had no previous contact with these GP trainers, but having experience in the training program was selected to interview GPs to encourage frankness of their views. The interviews took place in the teachers' practices. Open-ended exploratory questions were posed to interviewees to obtain their views. Interviews were audio taped, and field notes were made by the interviewer. Interviews were transcribed verbatim. Interviews were studied to get underlying meaning and then coded. Codes were then reduced to themes by grouping codes that relate to each other. To ensure reliability analysis was done independently by two investigators. There were no notable discrepancies in their conclusions.
| Results|| |
Why do they like to teach students?
General practitioner trainers were enthusiastic about training students. Altruistic reasons, self-satisfaction of helping students, self-esteem of being a trainer, pleasure of getting involved in teaching, drive and opportunity to improve their knowledge were some of the reasons for their involvement in teaching. Another expression was that teaching broke the monotony of everyday work.
"You get the satisfaction of helping young people and helping them to take one step forward in life."
"I become more outstanding, than other GPs, because I'm recognized as a GP teacher."
"I will be respected by my patients."
"Because I get a pleasure from it."
"Whatever I have learnt 35 years ago at medical school has changed, so it is a great opportunity for me to learn."
General practitioners' knowledge and skills in teaching
Trainers were aware of the objectives of the training. They were confident about their knowledge and their role as trainers. They admitted that they tried to improve their knowledge by reading books and journals.
What can be taught?
Concepts of family medicine, common problems, importance of psychosocial aspects in health and disease, doctor patient relationship, art of family medicine, history taking and examination, record keeping, practice organization and management were the key areas they taught students. They were of the view that three visits, which took place once a week were not sufficient to teach procedural skills, progression of illness and continuity of care adequately.
Patients' attitudes towards students
General practitioners perceived that the majority of the patients understood and liked the presence of students. Usually, patients accepted students during history taking, but when they had to discuss confidential issues some patients were uncomfortable. Most of the patients allowed students to present when they were examined without taking off clothes. When it comes to examination of genital organs most of the GPs did not allow students to present.
They emphasized that patients should be aware of the presence of students before entering the consultation room. Trainers observed that students should be introduced at the outset and consent should be obtained to avoid dissatisfaction.
Impact on consultation dynamics
Doctor patient relationship
General practitioners were of the view that doctor patient relationship was not affected most of the time, but occasionally there were instances where patients were reluctant to discuss intimate issues in front of students. They emphasized that patients should be watched for their reaction throughout. If it is realized that patients become uncomfortable students should be asked to leave the consultation room.
"Look at the patient, you know whether she/he is comfortable with students. So if they feel uncomfortable I send students away. When discussing confidential issues also I do the same."
"Sometimes we face the issue of confidentiality."
Quality of consultation
A constant theme emerged was that quality of the consultation improved when students were present, since they had to take a thorough history and stick to the correct technique in examination. They would not take short cuts which they might otherwise take in the presence of students.
"I think the quality is better. Because we are also careful, we don't take short cuts when there are students."
Duration of consultation
General practitioner trainers pointed out that duration of consultation increased due to students. Another opinion was that it depended on the condition of the patient and his/her willingness to get involved with the training process.
"That of course gets prolonged, when there are students. Because you have to explain and you can't take short cuts."
"It depends on patients as well, when they are prepared to spend the time we discuss more."
General practitioners highlighted that they did not change their pattern of prescription due to the presence of students. In fact they thought it was important for students to know what they prescribed.
"No, if I change they don't know exactly what should be given to the patient."
Number of patients seen during a session
There was a dichotomy of opinion. Most of the GPs were of the view that the number of patients they could see was less but others thought they saw the same number but they had to work longer during a session.
"Obviously it decreases. Because it takes a bit of long time for a consultation."
"It is the same, but I have to work little longer."
In general, they were happy with the theory knowledge of the students but not so with the practical and procedural aspects. They opined that 4 th year and final year students could understand and learn more since they had better knowledge.
General practitioners pointed out that at the beginning they (students) thought primary care was a superficial thing and they didn't take it seriously, but by the time they came for the third visit they had changed and appreciated the difference between primary care and tertiary care and had more respect.
They have noticed that more mature students were keen and more interested in learning than students of the 3 rd year and early part of 4 th year. They attributed it to the more background knowledge of senior students. Another opinion was that having to sit for an examination made students more enthusiastic. Simultaneously when it was too close to the examination also students were not interested. They had never experienced major problems with students, but there had been a few occasions where students were late, wanted to leave early and put forward excuses to keep away from training sessions. In general, students had been keen, obedient and respectful.
"If they are in the 3 rd or early part of the 4 th year they don't have background knowledge, they are not so interested."
"Those who have it (family medicine) as part of their clinical examination are more interested."
Number of students per session
Ideal number of students they liked to teach at a time was 2, which they could accommodate in their consultation rooms without a problem. The maximum they could accommodate was 3.
"If >3 students come, it's difficult to handle with the available space of the consultation room."
"Maximum three but the ideal is two."
Time has been the key problem for many. They managed the space by allowing only two or three students at a time.
"Time is the main problem. Patients start to complain, otherwise I love teaching."
"They (patients) hurry sometimes and when students are there they think that we take a long time."
"Space of course I don't like to take >2."
Support from the faculty
They pointed out that they had only a very little contact with the university. They expected the medical school to keep them informed about the changes and how they should change. They expected university to organize teacher training workshops to make the training uniform in all the practices. Some of them liked to have feedback from students on the training.
"So you have to keep us inform about the changes and how you want us to change. Teaching workshops should be arranged on a convenient day."
"Organizing teaching workshop to train all teachers. We should have a uniformity of teaching."
"I would like to have students' feedback."
Remuneration from the university
They were of the view that payment made by the university was a negligible amount but they were prepared to teach students without any payment from university.
"Even if they don't send a payment, I don't mind."
"I'm satisfied with what I'm given."
Willingness to teach in the future
Constant theme was that everybody would like to continue with teaching in the years to come.
"I will continue teaching as long as I can."
| Discussion|| |
For this qualitative study, GP trainers were purposively selected to represent different backgrounds. This was to facilitate maximum variability in their views, but there was a striking homogeneity in their responses. Gender, age, practice characteristics or location (urban, semi urban) have not affected their views. In general their views reflected positive attitudes even though the interviewer explicitly asked about negative effects. An independent Interviewer having no prior contact with the GP trainers was selected to conduct interviews to facilitate disclosure of negative feelings. However the sample of doctors interviewed was a specific group who had volunteered to train students, attended teacher training workshops and taught undergraduates for more than a decade uninterrupted.
General practitioner trainers' willingness to train students in their practices seems to be driven largely by altruism, self-satisfaction and self-esteem. The reasons expressed by GP the trainers were in line with the literature. A study carried out in UK reported that teaching medical students had a positive effect on GPs' morale and professional self-image.  Enhanced sense of self-worth and confidence  and welcome role as 'teachers of medical students  were also identified as potential benefits of teaching. Similar to the findings of this study GP trainers in London also revealed that students added variety to their work, reduced isolation and increased the morale of the whole practice. 
Improvement of knowledge was a beneficial effect of teaching students and this could be attributed to increased reading and reflection on practice, information from students, challenging questions from students and more time with patients.  Positive effects on clinical practice such as more methodical in clinical examination, management and maintaining records and selective in referral had been reported. 
Their awareness in learning outcome could be attributed to their long standing association with the medical school and medical school's strategy of informing them about the objectives regularly. Even though there are reports about anxiety among GP teachers regarding the adequacy of their knowledge and competence in skills,  the participants of this study were confident about their knowledge and skills in teaching perhaps due to longstanding experience of teaching. A few participants liked to have feedback from students, which university can arrange easily. Probably, they want an affirmation of their role as teachers. It has been reported that positive feedback from students was important for teachers' morale and insufficient feedback led to disappointment. 
It is interesting that GPs were able teach important aspects of health care which students could not learn in a hospital setup. Insufficient exposure to continuity of care should be taken into account seriously since this is one of the most unique features in family medicine. Increasing the number of visits is a possible solution. Fewer opportunities to learn procedural skills in general practices has been a constant finding previously as well, , but this need not be considered as a drawback in training since students could learn and practice these skills in hospital. 
Those who have trained students from other medical schools also made a comparison between students belonged to different levels of training. GP trainers were of the view that senior students, having more background knowledge could gain more from the training. It is the nature of general practice that one encounters a broad spectrum of problems. To understand and appreciate management of varying health problems students should have adequate background knowledge.
General practitioners perceived that the vast majority of the patients accepted and liked the presence of students despite the fact that they had to pay from their pocket for the service. According to a study carried out in Australia, GPs had a feeling that private fee-paying patients were less prepared to accept active student involvement compared with those in bulk billing practices.  Such a comparison was not possible here as all the patients were private fee-paying patients. The fact that the participants have been trainers for more than a decade could have influence over positive attitudes of patients. Literature shows that there is a tendency for consent rates to increase over time as practice teaching culture becomes more and more established. 
General practitioner trainers were of the view that the quality of care (consultation) improved due to the presence of students. Longer consultation time, comprehensiveness in history taking and examination, more methodical in management were the potential benefits to the patients according to GPs.
It is not surprising that students have a low impression about primary medical care as they start visiting general practices. A general practice is quite different to the sophisticated hospital set up where students have undergone training most of the time. It is an encouragement that students' attitude changes as they are exposed to the set up. They perceived that assessment made students more enthusiastic and it is an accepted fact among educationists.  Trainers were generally happy with the behavior and attitudes of students even though they had experienced a few incidents regarding the professionalism of students, including punctuality, respect and commitment. Sturman  in his study also reported occasional such incidents in her study.
Time pressures and space were common problems faced by GP trainers. According to most of the trainers presence of students increased consultation length and lengthen their workday. It has been reported that time pressures led to anxiety among trainers because of loss of clinical time due to teaching and preparation.  Obviously, the consultation room should have sufficient space to accommodate two or three students. Pearce et al. described a lack of time, work load and insufficient space as challenges of teaching in general practice. 
They expected the university to keep them informed and make them aware of the changes that take place. Their request to organize teacher training workshops to sharpen their skills in teaching and to make the training uniform in all the practices is appreciable. Obtaining skills in teaching was described as a challenge by Pearce et al. and they also recommended departments of general practice should provide resources for GPs to gain appropriate teaching skills. 
General practitioners in the community are rather isolated with little contact with their colleagues and they have limited opportunities for continuous professional development. It is extremely important to help them to enhance their knowledge and teaching skills, which will invariably boost their morale, confidence, and enthusiasm in teaching. This will eventually benefit students.
The honorarium they received was negligible as one GP trainer pointed out, but they were not bothered about it and had never complained probably due to altruism. They would like to continue with training students in the years to come. Their service should be recognized by the university and the public. This university appoints GP trainers as visiting lecturers which gives them academic status and could be rewarded further by awards and publicity.
It should not be forgotten that there are both direct and indirect costs involved with teaching. To get involved in teaching, a practice needs to expand beyond the provision of core clinical services. Infrastructure and organizational changes are necessary to provide both the training and patient care. It is essential to balance both components since adequate number of patients is essential to sustain both practice and teaching. In UK and Australia GP trainers receive a reasonable allowance for their service and even improvement to infrastructure. ,
| Conclusions and Recommendations|| |
- Altruism, self-satisfaction and self-esteem are main reasons for GPs' involvement in undergraduate training
- Patients have positive attitudes towards students
- Students could learn different aspects of medicine which they cannot acquire in a hospital setup. More training sessions are needed to expose them to continuity of care
- Mature students will be benefited more from training
- Time pressures and space were the main problems faced by GP trainers
- University should organize workshops periodically to update their knowledge and enhance teaching skills.
| References|| |
Hartley S, Macfarlane F, Gantley M, Murray E. Influence on general practitioners of teaching undergraduates: Qualitative study of London general practitioner teachers. BMJ 1999;319:1168-71.
General Medical Council. Tomorrow's Doctors: Recommendations on Undergraduate Medical Education. London: General Medical Council; 1993.
Available from: http://www.gmc-uk.org/10a_Review_of_Tomorrow_s_Doctors.pdf_25397631.pdf. [Last accessed on 2014 Mar 06].
World Federation for Medical Education. Proceedings of the world summit on medical education. Med Educ 1994;28 Suppl 1: 1219-28.
World Health Organization. Declaration of Alma-Ata. Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 'Health for all' Series No. 1. Geneva: WHO; 1978.
Mathers J, Parry J, Lewis S, Greenfield S. What impact will an increased number of teaching general practices have on patients, doctors and medical students? Med Educ 2004;38:1219-28.
Thistlethwaite JE, Jacobs H, Rudolphy S. Undergraduate general practice attachments - implications and challenges. Aust Fam Physician 2005;34:181-2.
O'Sullivan M, Martin J, Murray E. Students' perceptions of the relative advantages and disadvantages of community-based and hospital-based teaching: A qualitative study. Med Educ 2000;34:648-55.
Vinker S, Monnickendam S, Cohen O, Zalewski S, Kitai E. The influence of the presence of students on the consultation - Attitudes of tutors in family medicine clinics. Harefuah 2001;140:400-2, 454.
O'Flynn N, Spencer J, Jones R. Consent and confidentiality in teaching in general practice: Survey of patients' views on presence of students. BMJ 1997;315:1142.
Gray J, Fine B. General practitioner teaching in the community: A study of their teaching experience and interest in undergraduate teaching in the future. BMJ 1997;47:623-6.
Vinson DC, Paden C, Devera-Sales A, Marshall B, Waters EC. Teaching medical students in community-based practices: A national survey of generalist physicians. J Fam Pract 1997;45:487-94.
Australian Medical Association. Code of ethics, 2004. Editorially revised 2006. Available from: http://www.ama.com.au/codeofethics. [Last accessed date on 2014 Jun 03].
Medical Board of Australia. Good medical practice: A code of conduct for doctors in Australia, 2010. Available from: http://www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx. [Last accessed date on 2014 Jun 03].
Morrison J, Watt G. New century, new challenges for community based medical education. Med Educ 2003;37:2-3.
Metcalfe D. Family medicine: In from the periphery in medical education. Sri Lankan Fam Physician 1999;22:3-7.
Lefford F, McCrorie P, Perrin F. A survey of medical undergraduate community-based teaching: Taking undergraduate teaching into the community. Med Educ 1994;28:312-5.
Grant A, Robling M. Introducing undergraduate medical teaching into general practice: An action research study. Med Teach 2006;28:e192-7.
Sturman N. Teaching medical students-ethical challenges. Aust Fam Physician 2011;40:992-5.
Pearce R, Laurence CO, Black LE, Stocks N. The challenges of teaching in a general practice setting. Med J Aust 2007;187:129-32.