Organisation and Structure of Teaching

Several features of practice organisation have already been described. The particular issues of communication and the division of labour with multilevel learners will be considered.

7.5.6.1 Impact of one or several GPs leading on teaching

GPs from two types of teaching practices were interviewed: those from practices where the same person leads on postgraduate training and undergraduate

teaching and those from practices where different people lead on each of these. One of the purposes of this thesis is to reflect on what appears to work and why. It was clear from the interviews that different approaches worked in different

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practices and that in practices where different people lead on each, perhaps unsurprisingly, segregation of the two activities was a lot more common and marked.

I think they are probable seen as two separate things by the practice… Different people have responsibility for the two different things so there’s not much crossover there…I suppose I’m not fully aware of what the trainer does with the trainees and I know that my colleagues are not fully aware of what I do with the students. [For example], last week, my colleague who does the training said “Oh, I didn’t realise that you marked their assessments. I thought they went off to the university”. So you know we've [obviously never] had that

conversation about what is actually involved. (F5)

One difference that was noticeable, and could be expected, was that those GPs interviewed who were only leading on undergraduate teaching in their practice had an appreciation that training was more work but were less aware of the details of what was involved. One tutor described her experience of trying to find out more about training by attending a “training for non-trainers” event:

Well, a couple of years ago, I went to a training for non-trainers event. And to be honest, it was pretty useless. It didn’t really tell me anything… I think I was looking for more structure… but the training course itself is very in-depth. There’s lots of structure and education speak and things like that. (F4)

7.5.6.2 Activity theory interpretation

Each practice could be represented by its own activity system mapping similar to the mapping of each interview. Common to all mapping is the primary

contradiction between delivering teaching and service. The practice and its wider community are common to both and there may be some overlap in tools utilised. The formal external rules are different between the external

organisations and how these influence each practice may vary. There would be differences in the subjects and intended outcomes of teaching based on the level of learners being taught, how that labour is divided among the GPs in the practice and the underpinning values of each practice.

In practices where the same individual leads on both undergraduate and postgraduate education, integration and overlap of the practice-based

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GP who was a postgraduate trainer described using teaching resources (tools) that he used with the trainees for the medical students. In practices where different people do both, it is more likely for quite separate activity systems to exist. For example, those who led only on undergraduate teaching described being relatively unaware of postgraduate assessment requirements. Figure 7-20 demonstrates areas of likely overlap within a practice where different

individuals lead on different components of teaching.

Figure 7-20 Locations of overlap in the Activity Systems where different GPs lead on postgraduate and undergraduate

7.5.6.3 Communication within the practice team

Communication relevant to teaching was both formal and informal within practices. Informal discussions over coffee or in corridors, electronic

communication and formal meetings all supported teaching in different and often complementary ways. Although different individuals may lead on each level of teaching within practices, the preferred methods of communication were the same across the board for each team.

A striking feature of a majority of interviews was the importance of the coffee room as a focus for communication. Exceptions were two practices that worked

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across sites and one with no coffee room. The coffee room appeared to represent a place for learning, for sharing information and uncertainty, for supporting each other and working as a team.

We have a morning meeting... a coffee break…We have a regular chat and it's feedback about difficult cases. The trainees bring interesting cases, the students talk about amazing things they’ve just seen and it's quite good…We also discuss the overnight or weekend cases so that we are all abreast of what's going on. And by meeting every day … we pass things around and actually sometimes you make a decision about something there and then, without having to wait for a partners’ meeting a month away. So we can actually decide things and do things…very quickly and that can involve trainees and the students. …It's just saying, if you have a practice team that talks to each other fairly regularly, and has a chat and a laugh, and a bit of support, actually that makes a good working environment. (M2)

No one is allowed to go and sit at their desk and eat on their own. They have got to go away from their desk and… be away from their work. That’s just a rule. Everybody does it… It encourages them to share the things that have been difficult for them in the morning because it's about relationships isn’t it? And it's about feeling

supported, feeling that people are listening to you and if I’ve had a [bad] day then I can tell my colleagues that and they can go ‘Oh, that was nonsense.’ (F7)

Practices with significant amounts of multi-site working are more likely to communicate electronically using email and other messaging systems (e.g. EMIS tasks, Click Memo) to support working across sites. Although trainees and FY doctors will be included in these communications, students are not. In addition to this, a couple of single site GPs described intentionally using internal

electronic communication to seek feedback on students and to support sharing concerns about learners.

We tend to do a bit of chitchat from that point of view anyway but obviously, the other thing we can use is the tasks on the EMIS. So I would send a message to… the other GPs, so it's not being viewed by anybody else, but highlighting if there's some kind of issue going on there. And I use that for information sharing in a confidential way, particularly if you maybe do have trainees floating about the practice and you’re not wanting to go and have a chitchat with your colleague, in case the door opens and they over hear you (F6)

I will do a formative assessment halfway through. I email all the people that have been involved with the student up till that point and I ask for some feedback and my e-mail is usually quite structured. It’s

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structured…‘It’s great if I could get some feedback [on NAME]… and if you could put it under the headings knowledge, skills and attributes.’ (F3)

Supervisors vary in their approaches to collecting feedback on their students. In contrast to the structured approach above, this tutor is more informal.

It's mainly informal… I’ll just ask…and often the doctors feedback to me if they’ve had the student in or they’ve been out on calls or

something with them…. It's quite an informal thing and often…the day before their end of block assessment at the practice meeting [I will just ask] …if anybody has any particular feedback on this student…but they know to let me know if they have any concerns or if the student didn’t turn up or anything like that. (F5)

Despite the range of approaches to collecting information, it was clear from the interviews that all the GPs valued input from their colleagues and indeed felt this was essential if they had a struggling learner.

So we made the plan together, NAME was his lead trainer but we all did some of it because in terms of recording, because we weren’t sure he was going to pass. So, in terms of recording for… the e-portfolio… we needed all of us to make comment on that. So that it just wasn’t one person saying ‘Actually, I don’t think you are good enough’. It was everybody saying ‘Well, this is better. That’s better. This isn’t.’…so there was continuity in our team. (F7)

Several GPs also emphasised that even though responsibility for teaching was shared, a clearly designated tutor was important in case there were concerns. It was felt that issues were best dealt with by talking about them as they arose. Formal practice meetings were sometimes used to address teaching issues though more often these were reserved for practice business. All practices that had regular educational meetings emphasised that these were open for learners at all levels to attend but not all practices had these.

7.5.6.4 Activity theory interpretation

Communication related to teaching within the practice team appeared to reflect the general culture and patterns used for clinical communication within each practice. AT allows recognition of the boundary crossing of tools between these systems e.g. electronic communication tools (Figure 7-21). A striking feature was the importance for many practices of the informal discussions over morning

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coffee. These function both as a teaching tool and as an opportunity to support each other through the challenges of daily practice. In the practices where this time was clearly valued it was often the most obvious example of the continuum of medical education functioning in clinical practice.

Figure 7-21 The role of communication within the practice team to support teaching in multilevel learner practices