Practice characteristics

The GPs involved in this study were from a range of different practices across the West of Scotland and, from the group studied, it was clear that various attributes shaped teaching in those practices in several ways. Practice size, geographical location, patient and GP workforce demographics, were all influential.

7.5.3.1 Practice size

A positive side of smaller practices was that different learners’ paths were more likely to cross and it appeared to be easier to have a much more personalised approach to teaching and training. A couple of GPs commented that the students and FY2s seemed to value the one-to-one relationship in a GP setting, in

comparison to a more technology-orientated hospital setting:

I think if you want somebody to pay attention to what you are doing and learn from what you are doing as a doctor… there has to be a kind of relationship there. I'm not a surgeon doing stereotactic brain

surgery so you can’t put what I do on a screen and just get them to watch it without me there… For me it has to be an interaction between us [and] the patient. The three people in the room are all involved and talk about it and the patients love having students and… I’ll talk to a student about the patient with their consent in front of

9253421

the patient… Hopefully that’s what the main strength is, that they just feel that we are actually interested in them. (F2)

The main downside for smaller practices was the impact of GP absence as described above, as these practices have less spare capacity in the system. 7.5.3.2 Geographical location

Geographical location of the practice was described as being important in two main types of practices; those formally classified as rural practices and those which were peripheral to Glasgow, particularly in Ayrshire, Lanarkshire and Forth Valley. Four GPs interviewed were based in practices that had branch surgeries which brought challenges and opportunities e.g. additional travel time for GPs and learners. For the GPs, travelling between sites ate into already precious time and supervision of learners across sites was a consideration.

I’d love to have more time for tutorials and things, to have more time to talk. It's split sites we have to travel between so that makes that quite difficult… Because we are on three sites… things like…reviewing people’s surgeries after [they’ve] done them..and stuff like that [is more difficult]. So that could be anyone who is responsible. (M9) Travel to the practice was also an issue for learners allocated to the more peripheral practices. The rural practices provided accommodation for students and, in one case, the GP described the practice having to spend more on the cost of accommodation than they were remunerated by the university for

hosting the student. They now have this fully reimbursed but essentially provide their teaching for no income, as their funding goes towards accommodation costs for the students. As discussed in 7.4.6, a few of the practices that are on the peripheries felt their geographical location had a detrimental effect on their trainee allocation.

We try quite hard to give what we think is a good deal but still the fact that we are 20 miles from TOWN OUTSIDE GLASGOW means that nobody would possibly ever dream of venturing this far south and that’s disappointing. (M10)

Practices were aware that their location affected students and had tried to make things easier for the students coming there.

9253421

Because we’re quite peripheral, we’re quite difficult to get to. If they’re coming by public transport [and] they’ve gotta be in for 9, they’ve got to leave Glasgow at 6 in the morning. So we tend to say come in for about quarter past nine/half nine and then we teach through lunchtime…We give them lunch ‘cos…it’s difficult to get any food anywhere [here]… If they come by train we just say get a taxi and we’ll pay for…the taxi. And we’ll either get them a taxi back down or if I’m free I’ll take them to the station, ‘cos it’s a bit unfair, ‘cos it’s two buses as well. (M5)

A couple of the rural GPs were conscious of the risk of students feeling isolated on placements so involved them in social activities with the practice team. Only two GPs interviewed for this study mentioned doing any out-of-hours work with their learners and these were both rural GPs. One GP had stopped doing out-of- hours work as he felt the local service was unsafe and the second GP tried to involve the learners where suitable, feeling it was an important part of them developing an understanding and appreciation of life as a rural GP.

Some of our students we have up to our house and they end up…doing an on call shift with you… A lot of us have spare bedrooms… so it's not unusual for… students, if appropriate and…right for their training [to] stay over [when you’re] on call, so that, if you get called to

something, they can see that. And equally, as you know, sometimes if they are staying somewhere more isolated then it's quite nice for them to be somewhere where it's a bit more homely. (M3)

On a further positive note, GPs commented on the valuable experience that could be gained by seeing patients in more remote settings. This included at community hospitals or at branch surgeries.

The other big part of teaching here is we go to the community hospital… We have got a really huge advantage here in that students can follow patients right through to admission. So, they see them in the surgery with a sore belly. Say it's a kid, for example, with query appendicitis…they will go up to the hospital initially for some

stabilisation…while waiting transfer… (M3)

You’re that little bit further away from HOSPITAL NAME, the treatment room, the resuscitation facilities you’re just a little bit more exposed and so that’s a good opportunity to talk to them about issues of remoteness. (M1)

The importance of students respecting patient confidentiality came across in several interviews but was felt to be particularly relevant to rural practice when students were based there for the duration of their attachment.

9253421

We put a lot of time into an initial induction to go over confidentiality to explain…you are likely to come across this particular scenario, you are going to see a patient you might have met during the day, you potentially found an embarrassing or non-embarrassing problem and you will come across in the pub, or in the restaurants, or in the co-op. Think ahead on how you are going to handle that and then even quite complex things like sort of negative confidentiality so someone says ‘Oh, I heard that such and such was at the hospital but they are doing okay now, aren’t they?’ (M3)

7.5.3.3 Patient demographics

In the urban practices studied, two demographic features are of particular note: a culturally diverse patient population and the impact of deprivation.

One of the GPs described working in a ‘very multicultural practice’ and the rich experience that could bring for learners at all levels. She estimated that thirty percent of their patients don’t speak English and that it would be commonplace for there to be four appointments a day with interpreters. While presenting this as a positive learning experience she also described the impact of cultural differences on learners’ opportunities in her practice.

The male students find it [challenging sometimes] because they get kicked out if a Muslim woman comes in…so it's just being culturally aware. (F1)

Deprivation was felt to be important by two of the GPs based in deprived practices in Scotland. One described how a lack of transportation and a more chaotic patient population made it harder for her to organise planned teaching activities (e.g. third year signs and symptoms teaching) in an otherwise willing patient population.

They’re…very good at when they phone for an appointment in the morning or they phone for one the week before and they’re told there will be students in. Almost universally they are absolutely happy, they are used to it being a teaching practice…Quite often it falls through [on the] day. If it’s raining, it’s miserable, why would somebody want to come out? (F4)

Several GPs commented on being mindful of the burden on their patients of their significant involvement in teaching. In the practice above, the GP describes spending time reassuring patients that they were “giving the right answers” to

9253421

students when they had agreed to be portfolio case patients. There are no similar comments from other practices to comment whether this seemed to related to being in a more deprived area but the tutor did feel that this was relevant.

They very much worry that they’re not getting it right, they...worried that somehow they were going to ruin it for the students. (F4)

7.5.3.4 Activity Theory Interpretation - Practice characteristics

A key feature of sociocultural learning theories such as AT is that the individual is inseparable from their social context and that the activity is therefore shaped by that context. As described above, the geographical location, practice size and patient populations shape the teaching and learning occurring in practices in a range of ways. Rural practices can offer different learning opportunities to trainees (e.g. branch surgeries, community hospitals, overnight on call shifts) while, for other students, practice size may impact on the intensity of the student-supervisor relationship.

To illustrate how practice characteristics can create tensions and offer different tools to support teaching, the perspective of a rural practice is presented

(Figure 7-17). Tension is present within the community component of the activity system. On one hand, students are potentially at higher risk of feeling isolated as they are away from home and their usual social networks. On the other hand, they could potentially become much more immersed in the practice and local communities due to the nature of these placements e.g. living in the village and socialising with practice members and patients. This greater

likelihood of immersion also creates a potential tension with the rule of confidentiality. This was raised as a more likely dilemma for learners placed rurally and tutors specifically made a point of discussing this with learners at their inductions to try and negate this.

9253421

Figure 7-17 Teaching multilevel learners in rural practice - an example of the impact of practice characteristics on teaching