Video training with peer feedback in real-time consultation: acceptability and feasibility in a general-practice setting.
ABSTRACT: OBJECTIVE:Since many years, teaching and training in communication skills are cornerstones in the medical education curriculum. Although video recording in a real-time consultation is expected to positively contribute to the learning process, research on this topic is scarce. This study will focus on the feasibility and acceptability of video recording during real-time patient encounters performed by general practitioner (GP) trainees. METHOD:The primary research question addressed the experiences (defined as feasibility and acceptability) of GP trainees in video-recorded vocational training in a general practice. The second research question addressed the appraisal of this training. The procedure of video-recorded training is developed, refined and validated by the Academic Teaching Practice of Leuven since 1974 (Faculty of Medicine of the University of Leuven). The study is set up as a cross-sectional survey without follow-up. Outcome measures were defined as 'feasibility and acceptability' (experiences of trainees) of the video-recorded training and were approached by a structured questionnaire with the opportunity to add free text comments. The studied sample consisted of all first-phase trainees of the GP Master 2011-2012 at the University of Leuven. RESULTS:Almost 70% of the trainees were positive about recording consultations. Nevertheless, over 60% believed that patients felt uncomfortable during the video-recorded encounter. Almost 90% noticed an improvement of own communication skills through the observation and evaluation of. Most students (85%) experienced the logistical issues as major barrier to perform video consultations on a regular base. CONCLUSIONS:This study lays the foundation stone for further exploration of the video training in real-time consultations. Both students and teachers on the field acknowledge that the power of imaging is underestimated in the training of communication and vocational skills. The development of supportive material and protocols will lower thresholds. PRACTICE IMPLICATIONS:Time investment for teachers could be tempered by bringing up students to peer tutors and by an accurate scheduling of the video training. The development of supportive material and protocols will lower thresholds. Further research should finally focus on long-term efficacy and efficiency in terms of learning outcomes and on the facilitation of the technical process.
Project description:BACKGROUND: Patient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars. METHODS/DESIGN: This is an ongoing prospective multi-site cohort study of general practice registrars' consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program. CONCLUSIONS: The study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap - the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars' patterns of practice (for example, prescribing practice) over the course of their training.
Project description:BACKGROUND:Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient's preferences and the general practitioner's (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other's consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other's EBM behaviour through observation, and by identifying aspects that influence their recognition. METHODS:We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n?=?22) were shown fragments of their own and their partner's consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner's actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other's considerations well with those who did not, we developed a model describing the aspects that influence the observer's recognition of an actor's EBM behaviour. RESULTS:Overall, there was moderate similarity between an actor's EBM behaviour and the observer's recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role. CONCLUSIONS:GP trainees and supervisors do not fully recognise EBM behaviour through observing each other's consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.
Project description:BACKGROUND:Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing. OBJECTIVE:To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years. MAIN MEASURES:The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015). KEY RESULTS:Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]). CONCLUSIONS:Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.
Project description:Many patients now turn to the internet as a resource for healthcare information and advice. However, patients' use of the internet to manage their health has been positioned as a potential source of strain on the doctor-patient relationship in primary care. The current evidence about what happens when internet-derived health information is introduced during consultations has relied on qualitative data derived from interview or questionnaire studies. The 'Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)' study combines questionnaire, interview and video-recorded consultation data to address this issue more fully.Three data collection methods are employed: preconsultation patient questionnaires, video-recorded consultations between general practitioners (GP) and patients, and semistructured interviews with GPs and patients. We seek to recruit 10 GPs practising in Southeast England. We aim to collect up to 30 patient questionnaires and video-recorded consultations per GP, yielding up to 300. Up to 30 patients (approximately three per participating GP) will be selected for interviews sampled for a wide range of sociodemographic characteristics, and a variety of ways the use of, or information from, the internet was present or absent during their consultation. We will interview all 10 participating GPs about their views of online health information, reflecting on their own usage of online information during consultations and their patients' references to online health information. Descriptive, conversation and thematic analysis will be used respectively for the patient questionnaires, video-recorded consultations and interviews.Ethical approval has been granted by the London-Camden & Kings Cross Research Ethics Committee. Alongside journal publications, dissemination activities include the creation of a toolkit to be shared with patients and doctors, to guide discussions of material from the internet in consultations.
Project description:AIMS AND METHODOLOGY: We invited 232 General Practice Trainees to complete an on-line questionnaire to assess how they rated their training for the task of paediatric prescribing and therapeutics in the community. RESULTS: Of the 166 (71%) respondents who completed the questionnaire, 26.5% recalled specific teaching about paediatric prescribing and 59.6% covering one or more relevant topic during their undergraduate years. Undertaking a paediatric post during vocational training was associated with greater prescribing confidence (P < 0.001); however, 35% of respondents were not intending to undertake such a post. CONCLUSION: This study suggests that many GP trainees perceive their paediatric prescribing training as inadequate.
Project description:BACKGROUND:Guidelines have proposed that GPs should have a central role as coordinators of care and support patients with cancer during all stages of treatment, follow-up, and rehabilitation. Multidisciplinary video consultation involving the patient with cancer, the oncologist, and the GP may help to define roles and tasks, and this resulting clarity may enable greater support for patients with cancer. AIM:To explore the consultation structure, content, and task clarification when a GP and an oncologist are attending a video consultation with a patient with cancer. DESIGN & SETTING:A qualitative study took place in the Region of Southern Denmark to investigate multidisciplinary video consultations, based on thematic analysis. METHOD:Recordings of 12 video consultations were analysed using the framework method. A combined deductive and inductive approach was undertaken. The deductive themes were selected based on a consultation guide given to the doctors before the consultations. RESULTS:The study identified 15 themes, which were grouped into the following three categories: the implications of sharing a consultation; consultation structure; and health concerns. CONCLUSION:Multidisciplinary video-based consultations with a patient and two health professionals succeeded in having a patient-centred communication style. In clarifying tasks between the GP and oncologist to support the patient, work-related issues and professional support for psychosocial challenges were always a task for the GP. Dissemination of this first-line evidence may improve acceptability among medical specialists and help assist GPs in supporting patients with cancer. However, focus on the involvement of relatives should be emphasised.
Project description:BACKGROUND:Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees. METHODS:We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T1) and 6 months after (T2). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs' role in EoLC. RESULTS:In total, 294 GP trainees (I: n?=?219; C: n?=?75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T1) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T1 (p?<?0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p?<?0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75). CONCLUSIONS:The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC.
Project description:Facing the upcoming shortage of primary care physicians (PCPs), medical and governmental organizations have recently made major investments to foster vocational training programs in Switzerland, designed to provide context-specific training for trainees in primary care practices. Less is known about the impact of these programs on the skills and specific knowledge of trainees. We aimed to evaluate the Cantonal program for vocational primary care training in the Canton of Zurich, Switzerland's largest Canton.We undertook a pretest-posttest study and surveyed physicians before and after participating in the Cantonal program for vocational primary care training in the Swiss Canton of Zurich. All trainees who participated in the program from 2013 until the end of 2015 were eligible. Primary outcome was the proportion of trainees being confident about their professional, organizational, examination and management skills before and after completing vocational training. Secondary outcomes were the proportion of trainees stating knowledge gain in entrepreneurship and the proportion of trainees being motivated to pursue a career as PCP.Data of 47 trainees participating in the vocational training between 2013 and 2015 were eligible. In total, 35 (74.5%) participated in the T1 survey and 34 (72.3%) in the T2 survey. At T2, significantly more trainees (T1: 11%-89%, T2: 79%-100%) stated to be at least "slightly confident" about their skills (p<0.05 for each individual skill). Knowledge gain in entrepreneurship was highly expected and experienced by the trainees (55%-77% of respondents) in case of medicine-specific contents, but hardly expected in case of general business contents (≤47% of respondents). Concerning trainees' motivation to pursue a career as PCP, we observed only a minimal, statistically insignificant change, suggesting that the vocational training did not alter trainees' preconceived career plans as PCP.Given the measured increase in confidence, evaluation of training programs should focus on operationalizing key skills of PCPs. Given the lack of change in trainees' motivation; however, statements about the effect of program implementation on national shortage of PCPs cannot be made.
Project description:BACKGROUND:General practice (GP) trainees may seek supervisor assistance to complete their patient consultations. This in-consultation assistance plays a key role in the supervisory oversight of trainees and in trainee learning. It may be obtained face-to-face, or using phone or messaging systems, and either in front of patients or outside their hearing. Trainee concerns about decreased patient impressions of their competence, and discomfort presenting patients within their hearing, act as barriers to seeking help during consultations. Little is known about the frequency and associations of trainee concerns about these patient-related barriers, or the various trainee-supervisor-patient configurations used to obtain in-consultation assistance. METHODS:Australian GP trainees rated their frequency of use of five specific configurations for obtaining in-consultation assistance, perceived change in patient impressions of their competence after this assistance, and relative trainee comfort presenting patients outside, compared to within, patients' hearing. Statistical analyses included descriptive statistics and multivariable logistic regression. RESULTS:Responses were received from 778 Australian GP trainees (response rate 89%). Help-seeking configurations did not differ between trainees at different training stages, except for greater use of electronic messaging in later stages. In-consultation assistance was most commonly provided by phone between trainee and supervisor consulting rooms, or outside the trainee's patient's hearing. Supervisor assistance in the trainee's room face-to-face with the patient was reported as either never or rarely obtained by 12% of respondents. More trainees (25%) perceived that patient impressions of their competence increased after help-seeking than perceived that these impressions decreased (19%). Most trainees (55%) preferred to present patients outside their hearing. Trainee age was the only variable associated with both patient-related barriers. CONCLUSION:Supervisors appear to have considerable influence over trainee help-seeking, including which configurations are used and trainee perceptions of patient-related barriers. In-consultation supervision may actually increase trainee perceptions of patient impressions of their competence. Many supervisors and trainees may benefit from additional educational and workplace interventions to facilitate comfortable and effective trainee help-seeking in front of patients. More work is required to understand the clinical and educational implications of different help-seeking configurations when trainees require 'just in time' supervisor assistance.
Project description:BACKGROUND:Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. METHODS:We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. RESULTS:Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n =?42) the patients' comments were positive. The video-recorded transcripts (n =?9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). CONCLUSION:GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).