Monitoring the patient mix of GP trainees: How to make it educationally relevant
Scholing van artsen in opleiding tot huisarts (aios) vindt voornamelijk plaats in de huisartsenpraktijk, waarbij het uiteraard van belang is dat ze met alle relevante patiëntgroepen in aanraking komen. Dat blijkt in de praktijk niet zo te zijn: aios zien bijvoorbeeld relatief weinig patiënten met chronische aandoeningen, vermoedelijk omdat deze vaak voor hun vaste huisarts kiezen. Een monitoringssysteem moet hier verandering in brengen.
- Het ontwikkelen van een monitoringssysteem, waarbij ziektebeelden op een educatief betekenisvolle manier zijn gegroepeerd, om in kaart te brengen of aios met alle relevante ziektebeelden in aanraking komen. En, in het verlengde daarvan, een interventie ontwikkelen om te kunnen bijsturen. Daarbij kijken we niet alleen naar barrières die patiënten ervaren en manieren om ze te motiveren wel naar de aios te gaan, maar ook naar de rol van andere betrokkenen.
- Inzicht verwerven in de samenhang tussen de prestaties van aios en de mate waarin ze met bepaalde ziektebeelden in aanraking zijn gekomen.
Auteur: S. De Bever, J. de Jong, N van Dijk, C.E.J van der Post, M.R.M. Visser
Samenvatting van de aanvraag
Postgraduate medical training programmes largely consist of workplace-based learning. The importance of an adequate patient mix for optimal learning in the workplace is recognized by several national and international accreditation standards[1-3]. Previous studies, including our own[4,5], have revealed areas of low exposure in the patient mix of GP trainees. These areas concern important patient groups for which GP care is becoming increasingly important, as stated in the recently published vision on GP Care in the Netherlands. It is thus unclear whether current GP trainees are optimally prepared for future patient care. Research is needed on possibilities for providing feedback on and steering the patient mix in order to fill existing gaps and to enhance insight into the relationship between patient mix and competency development. In our earlier work on patient mix and the learning of GP trainees, we developed an instrument for monitoring patient mix that used electronic patient record (EPR) systems. This instrument provided continuous and reliable feedback on the patient mix of trainees. Patient contacts were aggregated according to the International Classification of Primary Care (ICPC). We also tested an intervention for actively steering the patient mix of the GP trainees and establishing its effects on the self-efficacy and knowledge of trainees. The current proposal is a sequel to these studies. It involves a collaborative project between four of the eight GP training institutes in the Netherlands (Erasmus MC, LUMC, VUmc and AMC–UvA), which together represent over 50% of all GP trainees in the Netherlands. The project has three aims. The first aim is to describe patient mix in an educationally meaningful way (Study 1). The ICPC classification, which classifies diagnoses according to organ systems, was not designed for educational purposes. An educationally relevant description of patient mix can be obtained by clustering ICPC diagnosis codes according to the nine patient-related educational themes developed by Huisartsopleiding Nederland (HN; network of eight departments for specialty training for general practice and 1,800 GP trainers) to structure the curriculum . This description can be used for both formative feedback and research purposes. In developing these clusters we will make use of the prototype method of categorization, which assumes that elements of a category vary in the degree to which they are characteristic (prototypical) of that category [10,11]. The second aim is to enhance insight into the relationship between patient mix and competency development (Study 2). Patient mix will be operationalized by ICPC codes weighted for their prototypicality for an educational theme (results of Study 1). These will be related to the performance of trainees on entrustable professional activities (EPAs), which are defined as critical parts of professional work that can be identified as a unit to be entrusted to a trainee once sufficient competency has been achieved[12,13]. By using operationalizations of high educational relevance for both patient mix and competency development, we will enhance insight into the relationship between patient mix and learning. The third aim is to develop an intervention that can be used to fill the gaps in the patient mix of trainees. In an earlier attempt to steer patient mix, we focused on instructing the medical receptionist, who has the task of assigning patients to the available doctors. Trainers and trainees were also instructed, but patients were not involved. This intervention had only limited success . In Study 3, we will use focus groups to investigate more profoundly the motives the four involved parties (trainers, trainees, medical receptionists, patients) have regarding steering, as well as the barriers they face and what would help them to overcome those barriers. This will result in a theoretical model that will be used to design the steering intervention. The intervention will subsequently be piloted in GP practices. Again, the results will be used to refine the model and the intervention. Here, we will follow the guidelines on the development of complex interventions issued by the Medical Research Council . In conclusion, by adopting the educational themes that form the framework for the GP specialty training programme, this study will result in a monitoring system that provides highly relevant feedback on the patient mix of trainees and determines a suitable patient mix tailored to individual educational needs. Moreover, by developing an educationally relevant operationalization of patient mix, the clusters will help to improve research into the relationship between patient mix and workplace-based learning, which continues to form the main part of postgraduate education. By developing a steering intervention, we will increase our knowledge of how to influence patient mix according to learning needs.