Eamonn O’Shea
Western Training Programme in General Practice
Eamonn O'Shea, Western Training
Programme in General Practice
“To be trained is to arrive – to be educated is
to continue to travel”
Calman, 1994
Eamonn O'Shea, Western Training
Programme in General Practice
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Vocational training has been shown to be
effective
Recent suggestions that traditional 3 year
model is too short to produce independent,
capable family doctors
Reports of extended programmes show
◦ Increased enthusiasm for GP
◦ Increased confidence in GPR clinical judgement
◦ Makes GPR feel more prepared for independent
practice
Eamonn O'Shea, Western Training
Programme in General Practice
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Embarked on 4th year of training in April
2006
PLP in third year
Registrars allocated to a different practice
1 day release per week
25 % of this spent in group peer learning
Remaining time for private study, research,
hospital speciality attachments, pursuit of
further educational qualifications
Practice management project/audit
Eamonn O'Shea, Western Training
Programme in General Practice
To compare and contrast the expectations and
experiences of 3 distinct groups:
 GPs who completed the traditional 3 yr
training programme and were interviewed
after 1 year of independent practice
 GP registrars who were the first entrants into
the new extended year of training
 GP trainers who were the first trainers
involved in the extended year of training
Eamonn O'Shea, Western Training
Programme in General Practice
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Systematic, non-probabilistic sampling
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Focus groups
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Transcript analysis using an adapted version
of grounded theory analysis (Charmaz, 1973)
Emergent themes
Eamonn O'Shea, Western Training
Programme in General Practice
Focus Group
FG 1 March 06
FG 2 April 06
FG 3 April 06
FG 4 March 07
GP registrars
about to
commence extra
4th year of
training
GP trainers about
to commence
training new 4th
year registars
GP registrars after GP trainers after
completion of 4th completion of
year of training
training a 4th year
registrar
6 females 2
males
Mean age 28.75
yrs (range 2830))
5 from a possible 8 from a possible
6 (83%)
10 (80%)
7 males
Mean age 57.7
yrs (range 40-60)
5 females 2 males 8 males
Mean age 30.6
Mean age 53.9 yrs
yrs (range 29-35) (range 41-61)
7 from a possible
10 (70%)
7 from a possible
10 (70%)
8 from a possible
10 (80%)
Reason for
non
attendance
Resident in (1)
Work
commitments (3)
Annual leave (2)
Sick leave (1)
Work commitments
(1)
Annual leave (1)
Experience
Years as a doctor Years as a doctor Years as a trainer
6.2 yrs (range 6- 5.625 yrs (range Mean 12.7 yrs
7)
5-7)
(range 2-17 yrs)
Years as a doctor Years as a trainer
6.72 yrs (range 6- Mean 15.25 yrs
8)
(range 3-27 yrs)
Coding
Coded as Female Coded as Male
GP1, Male GP1 Registrar 1
(FGP1, MGP1) (MR1), Female
Registrar 2(FR2)
Coded as MR1,
FR1
Subjects
GPs with
traditional 3 year
training after 1
year of
independent
practice
Demographics 3 females 2
males
Mean age 31.7
yrs (range 29-39)
Attendance
Mat leave (1)
Annual leave (1)
Coded as Trainer
1, 2 (T1, T2)
Eamonn O'Shea, Western Training
Programme in General Practice
FG 5 March 07
Coded as Trainer
1,2 (T1, T2)
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Support & Protection
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Need for standardisation
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Preparation for the real world
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A new training relationship
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Individualised learning
Eamonn O'Shea, Western Training
Programme in General Practice
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4th year GPR
◦ Valued support received while on TP
◦ Valued protected time
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3 year graduates
◦ Missed regular contact with peers/PD
◦ Those in sessional work had v little support
◦ Those in assistantships were more reluctant to ask
questions of a senior partner
◦ ? False sense of security created on TP
Eamonn O'Shea, Western Training
Programme in General Practice
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“There was no one to discuss a case with”
FGP1
“You are afraid to ask stupid questions”
MGP1
“When you are a GP trainee no question is too
stupid” MGP2
Reflection on findings
Eamonn O'Shea, Western Training
Programme in General Practice
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GPR/Graduates
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Standardisation of training practices
Difference in expectations of GPR within practices
Need for protected time
Standardisation of financial aspects
Trainers
◦ Ideal practice or “Marks & Spencers” general
practice
Eamonn O'Shea, Western Training
Programme in General Practice
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“You feel then gosh if you had even a small question that
you wanted to ask but because of the time constraints
then or that you know that you’re already running late and
you’ve already got another 2 hours of that, that you avoid
going out to ask a question because you know you’re just
going to be delaying yourself by another 10 or 15 minutes,
I don’t think that’s any good”
FR5
There’s huge discrepancies between practices”
FR4
“I think if you are in a practice where the assistant can
keep the money from on call work and you have your
membership, I think it is ridiculous to be left in working all
weekend and hand over like every penny of it………even if
there was some recognition of the fact that you were there
on a Saturday or a Sunday”
FR4
Eamonn O'Shea, Western Training
Programme in General Practice
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“I don’t think that standardising practices would be such a great
idea I think it’s a great idea to see different practices, I wouldn’t
mind doing that myself to see what other people do” T2
“I think maybe once we have a contract, maybe our teaching time
and our tutorial time would be fairly standard. I think in terms of
the design of a practice and how its run you know we are all
different practitioners running different practices and I certainly
have over 30 years developed my practice the way I like to do it.
And I feel if the trainee likes it that’s great if they don’t like it
well you know, I think you have to take into account the trainees
ability, their speed of consultation and that should happen at the
beginning. But I don’t think we should become the Marks and
Spencers of General Practice.”
T5
Eamonn O'Shea, Western Training
Programme in General Practice
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3rd year group – underprepared for IP but
concerned that extension delayed becoming
independent
4th year group felt more prepared
◦ Experience of 2 practices
◦ Self directed learning
◦ Different nature of day release
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Trainers- mixed views
◦ More mature registrar – more interested in practice
management
◦ ? Still unrealistic protected time for learning
Eamonn O'Shea, Western Training
Programme in General Practice
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“It was a huge leap – you are suddenly cut off
completely”
FGP1
“Well I suppose the contrast of the seeing
different ways of how things are managed and
how the different principals deal with things. Its
more exposure to it, more experience ; you pick
up good points and bad points from each one of
the trainers. “ FR2
“Are we giving them the impression with all sorts
of protected time to do further courses that this
is the reality in general practice with busy
careers, family etc?” T2
Eamonn O'Shea, Western Training
Programme in General Practice
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“For me it was definitely a time that I built up my
confidence more than anything else, I am now way more
confident than I was and whether that’s a culmination of
just time but I think some of that was getting the extra
teaching, that bit of protection, a bit of everything, I think
the culmination for me is definitely more confidence.” FR4
“I would say a safer kind of confidence in the sense that
the 3rd year I always felt if you had 3rd year trainees who
were supremely confident and had no right to be so and
you had also trainees who felt themselves very inadequate
and lacked real confidence and there was no problem with
them. I think the 4th years have a better idea of where
they are at and what they can do. I think they are
probably, their confidence more fits where they are at.” T5
Eamonn O'Shea, Western Training
Programme in General Practice
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Trainers
◦ More mature outlook
◦ More mature interaction
◦ A greater challenge as registrars have prior training
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4th Year Registrars
◦ Tutorials less structured
◦ Less focus on exams/assessment
◦ Generally training received very worthwhile
Eamonn O'Shea, Western Training
Programme in General Practice
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“It is not really teaching anymore it is an exchange of
ideas”
T4
“It’s nice to have somebody who’s mature and
enthusiastic. My trainee certainly matured during that year
and I encouraged him to adopt ownership of patients of
responsibility and decision making and I felt I learnt from
him”
T8
“I think definitely trying to think how I am going to fill up
all these tutorials. Because I feel you know the thunder is
being stolen a bit by the 3rd year trainers. And you are
trying to figure out, having said that I thought there was
more motivation to learn about the nuts and bolts of a
practice, you know.”
T4
“Yeah I think the trainers found it a bit strange, they didn’t
know what they were meant to be talking to us about in
tutorials MR2
Eamonn O'Shea, Western Training
Programme in General Practice
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“Sometimes I think they take us a bit for
granted” FR1
“Because it strikes me in talking to the group
of trainees that you know their expectations
are very high but they do not realise that we
are doing this virtually free-gratis. And that
their demands of the practice you know what
they expect from us in return for what we are
getting, you know, they are poles apart. “
T6
Eamonn O'Shea, Western Training
Programme in General Practice
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4th Year Registrars
◦ Valued protected time
◦ Valued the programme being centred on their
needs
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Trainers
◦ Felt the continuity of care was disrupted
◦ Felt this could create unrealistic expectations of
learning opportunities in general practice
Eamonn O'Shea, Western Training
Programme in General Practice
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“Its good that we have choice, to decide what to
do ourselves for the fourth year; that was
definitely a positive thing about it.”
FR4
“I think it’s funny in hindsight, when we started
off I don’t think I was entirely happy about it and
now I have to say I think it was a fantastic
opportunity. I really, really enjoyed it and it
definitely gives you, it kind of focuses you a bit
more, makes you concentrate on doing other
stuff that you mightn’t have been necessarily
able to do or that you mightn’t be inclined to do
if you were under pressure going out on your
own and looking for a job.” FR2
Eamonn O'Shea, Western Training
Programme in General Practice
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“Unfortunately, the emphasis seems to be on
more exams and courses rather than “face to
face with patients building up flying hours”
T1
“It is everything but general practice”
T7
“There was a feeling that we talked about
that general practice is going to get eaten
into, that’s exactly what has happened, they
have contributed less time to general practice
than we thought they should have.”
T3
Eamonn O'Shea, Western Training
Programme in General Practice
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“You know I mean I had somebody tell me
that because I was just married that I was a
time bomb and nobody would employ me
now. You know they shouldn’t be allowed to
get away with that in this day and age do you
know what I mean.” FGP2
“Then I really found as a woman it was
discrimination against women, women were
offered the sessional stuff”
FGP1
Eamonn O'Shea, Western Training
Programme in General Practice
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“I have yet to meet a trainee who has any ambition other
than to be a sessional doctor.” T1
“All female are they?”
T8
“Yeah, yeah, and that is it, we can’t teach them to be
sessional doctors“ T1
“Now going back on the point, I’ve had 2 female doctors
who really wanted to go into general practice, one did
actually, she was very focused. I never got the feeling she
was going to be a sessional doctor. We had another girl
who was focused on getting a partnership, knew what she
wanted to do, so I don’t think its fair to generalise but I
would, you know, that’s my personal experience, the last 2
or 3 female GP trainees have been very focused and
wanted general practice as a career, a full time career.”
T3
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Eamonn O'Shea, Western Training
Programme in General Practice
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Registrars felt better prepared for the “real
world of independent practice
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^ confidence
Experience of working in different practices
^ knowledge of practice management
Career guidance received during extended year
A new training relationship is emerging:
mentor > trainer
Eamonn O'Shea, Western Training
Programme in General Practice
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Customised design of year provides an easier
transition to independent practice but
trainers concerned that it may create
unrealistic expectations
Dissonance between trainers and registrars
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Customised learning
Standardisation
Outlook
Expectations
Eamonn O'Shea, Western Training
Programme in General Practice
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Small number of groups and participants
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Limited to our geographical area
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Limitations of focus group approach
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Personal bias
Eamonn O'Shea, Western Training
Programme in General Practice
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Follow up of fourth year group to see if their
apparent confidence was sustained
Joint focus groups between trainers and
registrars to allow for exchange of views and
development of their relationship
Inclusion of other stakeholders in the
research: programme directors, patients,
other GPs and ancillary staff in training
practices.
Eamonn O'Shea, Western Training
Programme in General Practice
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Focus group participants
Dr Gennie McGuire and colleagues
Ms Pauline Clerkin
Prof Andrew Murphy
Dr Anne McFarlane
Dr Liam Glynn
Dr Peter Cantillon
Eamonn O'Shea, Western Training
Programme in General Practice