DR ALICE SHINERDR GREG IRVING

DR JESSICA WATSONDR JOANNE REEVE

PROFESSOR AMANDA HOWE

RCGP JUNIOR INTERNATIONAL COMMITTEE, UK

WONCA WORLD CONFERENCE, PRAGUE, JUNE 26 T H 2013

Future capacity for expert generalist care: a critical view of European training

Expert generalist practice

Informed by a view of the whole; defined by 2 elements:

• Principle of PERSONALISED DECISION MAKING, supporting personal illness care

• Practice of INTERPRETIVE MEDICINE: critical use of range of knowledge in dynamic exploration and interpretation of individual illness experience, including capacity to judge trustworthiness

(Reeve 2009)

Objective of study

To explore international colleagues’ views about how and whether training prepares them for expert generalist practice (EGP)

To ask the question:

“To what extent is expert generalist practice normalised into GP training across Europe?”

Methods

Two focus groups, conducted at the 2012 RCGP Annual Conference

Participants: 14 trainees/newly qualified GPs from 12 Wonca European countries

Because EGP is a complex intervention the interview schedules and data analysis were informed by the “Generalist Capacity Assessment framework” developed using Normalisation Process Theory

Sense making Engagement Action MonitoringData analysed using ‘Dedoose’ online software

Results: Sense-making

Trainees recognise the EGP role as one of “interpretation” and knowledge integration

They drew comparisons between EGP and the role of the specialist

Practice often viewed as “intuitive” and enhanced by experience, but not as “expert”; leaving trainees fearful of defending practice against external scrutiny

Evidence of participants implementing, continuing and even making changes to training to support EGP in the face of adversity (e.g. long hours)

Strong feeling that EGP requires continued practiceAnd that personal motivation matters

BUT external engagement was missing, with the perception that both other doctors and the wider health system fail to recognise the importance of EGP

Results: Engagement

Results: Action

Most stories were about being an ‘all-rounder’, but some were about the practice of EGP

The prime resource used to ‘do’ EGP was experience (i.e. seeing patients)

Other resources were role-modelling and peer sharing

There was little discussion about the boundaries and wider practice of the EGP role, e.g. how it fitted in with team-working

Results: Monitoring

Evidence that participants considered EGP worthwhile and evidence of continuous investment into person-centred practice

Most training involved feedback and reflexive appraisal, however there is room for more critical reflection

External monitoring focuses on financial/biomedical priorities and if anything constrains EGP

Conclusions

Trainees recognise EGP role as one “interpretation” and knowledge “integration”

Committed to and continually invest in EGP

Make sense of EGP by comparison with specialist

Room for more critical reflection

A lack of training in the critical judgment of interpretive practice

Limitations

Small sample, several countries missing

English was second language for all

participants

How much did participants understand what

we meant by EGP?

How this fits in

Forms part of a wider study examining the practice of generalist expertise (Reeve et al 2013) Highlights gaps in service design limiting

development and implementation of EGP

Australia: Gunn et al (2007) What is the place of Generalism in the 2020 primary

care workforce?

UK: RCGP Commission on Generalism (2012) Calls for extended and enhanced training

Recommendations

Sense Making Awareness raising campaign (inside and outside of

profession) Compare “All-rounder v EGP” A “summit” bringing key stakeholders together

Engagement Experiential learning: Medical school / GP training /

CPD Whole system approach to prioritising EGP

Recommendations

Action Curriculum review

“selectively gather and interpret information”….but how ?

Focus on areas at the boundary between Illness and Disease

CPD for Interpretive Medicine

Monitoring Blueprinting EGP learning outcomes to assessment

Focus on WPBA and CSA Tools needed to support critical reflection for trainees