Identity as a teaching practice

7.5.1.1 Starting and handing over teaching

Of the seventeen GPs, five had been responsible for setting up undergraduate teaching and three GP specialty training in their practices. Two out of the three that had set up training, had set up both. Therefore, the majority of GPs

interviewed had been ‘handed over’ their teaching role by a predecessor in the practice who had either retired or decided to stop training. In one particular practice, teaching dated back to the mid-seventies and it was handed over to him by his father. Most of the time, the GPs interviewed appeared to be enthusiastic recipients of their teaching role but on a few occasions due to practice circumstances or pressures the responsibility fell to them.

I’ve been a trainer five years…and I’m now our lead trainer, just through retirement and restructuring, so that was a quick step up. But it’s been fine, again the whole place is used to it. We have three trainers and our fourth partner is about to embark on training. (M6) My colleague who retired kind of persuaded me…he retired two years ago due to ill health and he was quite keen that we keep taking the students… He particularly enjoyed it and felt that because it was a training practice and because of the way it was set up, it was a good place to come. (F4)

Three GPs interviewed have either recently stopped training or are planning how they are going to pass the baton to a colleague. Succession planning is a

standard component of postgraduate training practice accreditation discussions. The GPs described this also being part of practice discussions and planning. In all

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the interviews conducted with long standing teaching and training practices, teaching came across as being an embedded part of their practice identity.

The whole ethos of the place is to do both, to do it all the time…I think it was something that was so established that it’s the right thing to do. (M6)

7.5.1.2 Activity Theory interpretation

AT prompts consideration of what those in the community consider to be their “work” through review of the value which practices place on teaching and the motivators for practices to teach. For the GPs that described teaching as being core to their practice’s identity, teaching is clearly almost as important as the clinical service they are primarily contracted to deliver. In AT, the historical context of an activity is important and the division of labour can suggest how teaching has developed and continues to develop within a practice community. Decision making in relation to establishing teaching, handing over teaching and succession planning were all part of discussions (Figure 7-13).

Figure 7-13 The history of teaching involvement in practices - starting and handing over teaching

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7.5.1.3 Impact on recruitment

For those that had helped establish or expand teaching within the practice themselves, a practice vision with education at the core was desirable and aspirational.

I’d really want the practice to have an educational focus, that’s the side of it that I like and that’s where I’d like it to head. (F6)

This shaped the development of the practices in a number of ways, most evidently in the choices that were made when it came to recruitment of GPs.

I enjoyed the practice I’d done my training in and felt that it kept you up-to-date…I quite liked the whole vibe of a training practice and that was part of the reason I got the job in this practice. ((F3)

We always thought it would be good to aim to be a training practice. That was kind of an aspiration…it meant that when we were recruiting we were looking for someone who was really interested in teaching. (M7)

The desire for likeminded colleagues when it came to practice appointments came across in many of the interviews.

I think the biggest and most important [resources]…are colleagues who understand and are interested in teaching and a decent admin (sic) contact. (M3)

For those in whom it did not, it was clear that the recruitment of any decent GP was their current priority.

For a couple of those who were able to prioritise an interest in education, this was based on their own negative experiences of colleagues unsupportive of teaching or that of others.

We have been in the situation previously where we had someone who wasn't as keen…Don't get me wrong, I know some of my friends have had it a lot worse than she was…but she would say “Oh, for goodness sake, how may tutorials do these [students] need?” and this kind of thing…It just gets annoying...because you are like, “oh [be quiet], you came here knowing that we were training, just [stop it]”. (F7)

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The example above illustrates the tension that differing opinions on teaching can cause. Two GPs reported that resistant colleagues had hindered teaching

delivery - one colleague stopped the practice teaching all together while the other prevented necessary training developments. In both of these practices, the situation only improved when the resistant individuals retired. These examples highlight the importance of whole practice commitment to teaching which will be discussed in Error! Reference source not found. .

7.5.1.4 Activity Theory interpretation

In 7.5.1.1, the perceived value of teaching alongside clinical practice was

highlighted. Having a full complement of GPs in the practice to deliver service is clearly the highest priority outcome from recruitment. Secondary to this, there is a desire to recruit GPs with a shared enthusiasm for teaching. When the latter has not happened the primary contradiction between teaching and service can emerge as a secondary contradiction (e.g. disagreements about division of labour) (Figure 7-14).

Figure 7-14 The impact on recruitment of teaching multilevel learners in general practice

7.5.1.5 Practice motivation to teach

Teaching was perceived to bring many benefits at both a practice and a personal level. Personal motivators will be explored in 7.6.1. From a practice point of view, the importance of practice identity as a teaching practice has already

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been highlighted with the majority of GPs in this study having been “handed- over” teaching responsibility. There is some variation in what practices feel teaching undergraduates brings as opposed to training postgraduates. While both are appreciated to bring income into the practice, postgraduates are

additionally recognised as hopefully bringing “a spare pair of hands”. One GP described the significant benefit of this in the past when there would have been a much more onerous on call.

In those days… we were doing a lot of on call. It was a 1 in 2, not very busy but very tiring and we decided our vision for the future, for the next 25 years…at least, [was to] go up the training route…It would give us a pool of resource to use. It's great. We have… trainees [who] can help out when they are very competent and can be left in charge. (M2)

The perception of the ability of GPSTs and FYs to contribute to workload is variable. In general, it was felt that the foundation doctors were effectively appointment-neutral, becoming more useful if allocated at later points in the year. A competent GPST3 towards the end of their year was felt to be a significant attribute but, in contrast, practices may struggle to support a struggling trainee.

On one hand they give you an extra pair of hands and sometimes a brilliant extra pair of hands…On the other hand…if they are no good, there's so much work and …I don’t see us having the manpower to put in the work if they are no good. (F2)

Practice attitudes to income generation from teaching were diverse. A couple of GPs interviewed identified income as an important factor in taking on teaching but it was never the sole motivating factor.

…one of the senior partners didn’t want to go back to training so we felt that doing medical students was an income stream, it kept us kind of a wee bit more in touch with the younger side. (F2)

[Why did we add in the medical student teaching?]...Money probably. The FY training, now that would be money too… They were keen to get people to do FY2 training and we weren’t entirely sold on how beneficial that would be for service provision point of view but we took it on...Most of the time we have had a…continuous succession of FY2s which I must say I’ve enjoyed very much. I’ve found it's possibly the most rewarding part of all the training. (M10)

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In contrast, a couple of GPs felt important to be clear that money was not a main motivator for the practice and, at one point, one of the rural practices interviewed was paying more for accommodation for the student than they were getting for hosting the student on placement.

We've put them up in a B&B, we pay for that and we had to negotiate with MEDICAL SCHOOL quite a lot because for a while it can actually end up costing more to host them than it is to get paid. (M2)

We’re not doing the teaching for the financial gain of it, really, it’s not worth that much. (M6)

One tutor even went so far as to suggest that he thought most practices would continue teaching even if the trainer’s grant was withdrawn.

The truth of it is… they could save a fortune… if they withdrew funding for all training. How many practices would stop training? Not many. I mean, you get the training grant but the reality of it is I’d bet you most…none of them would stop. They could save five grand a year on each one, I think that’s what it is. (M9)

Several GPs highlighted teaching as a way of keeping the practice up-to-date; both in terms of the requirements for being a teaching practice but also as a direct result of needing to keep up with the learners themselves.

It's really …making sure that the practice has got all the protocols and that we are doing things properly… It is a definite advance on three, four years ago. We have a regular clinical meeting every month now For many years that was the intention but it kept falling by the wayside… And maybe then it hopefully brings more consistency into what we do so it's a practice approach to something rather than an individual thing. (M7)

I think it's good for the practice in terms of making sure that we keep up-to-date with things, I think it does...give an atmosphere of

continued learning within the practice because there's people

training…I think it's good for raising standards as well… I think that we feel because we've always been a training practice that we do have quite high standards and quite good…clinical governance and all these kind of things so…I think it's positive from that point of view. (F5)

Additionally, the GPs felt the learners, particularly the students, bring an energy to the practice.

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A really important thing is it brings a lot into the practice and that, even as…a practice team of around about 40 people,…teaching in general, and particularly medical student teaching, brings in so much kind of energy that is really, really positive. (M3)

Students’ curiosity and lack of cynicism was welcomed in a couple of interviews. I think undergraduates…have a sort of freshness to their thinking that I think it's quite infectious. I mean…there's just something about having a young person in the practice, devoid of, usually devoid of, cynicism and the vast majority of our students are so curious. That I think feeds into the rest of the teaching practice and makes them better (M1) 7.5.1.6 Activity Theory interpretation

AT takes into account the historical context of an activity and the importance of a practice’s teaching history has already been explored. The range of motivating factors for teaching can be represented as different intended outcomes of the same object – teaching (Figure 7-15). These are not necessarily in conflict with each other and in fact can amplify the benefits of teaching. A clear potential source of tension in the system is when it is effectively “destabilised” by a struggling trainee. Not only are practices not able to deliver service as hoped, struggling trainees also require additional resource and this can impact on the intended outcomes of teaching.

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Figure 7-15 The range of practice motivations to teach in general practice