Dr Jane Barker explains the value of local GP placements for advanced-level medical students
When I first heard of the long-term student placements in general practice I wondered if and how they fitted into medical training. Longitudinal integrated clerkships, LICs for short, have now been proven to be effective learning environments for later-stage medical training.
The University Centre for Rural Health/North Coast (UCRH) has hosted students from Wollongong for the past 7 1/2 years, more than 150 students in all. Each of them has been allocated to a general practice in our area for two days a week for 38 weeks. In this four-year postgraduate program, this is effectively an eighth of their medical training.
For me the exciting part is that LICs claim what we have all known: that general practice can be a fertile learning environment, not only to teach Community Medicine but Medicine in general, that large teaching hospitals are not essential for all medical training and that there are aspects of medicine which are best learned in a general practice environment.
Medical training is complex, not least the assimilation of a very large volume of medical knowledge and its application to clinical reasoning and management. Students are required to master practical, communication and psychological skills, but also to develop what we would call the ‘Art of Medicine’ and all that that encompasses.
In the LIC GP program, particularly in a rural setting where GPs are involved in small hospital outpatient and inpatient care, students have the opportunity to practice all of these skills in a safe supported environment.
“Students comment regularly that they have never experienced doctor/patient relationships in the same way in a hospital setting, seeing the GPs in their many roles…”
In addition to this the general practice environment allows the student to enhance their practice through those areas that are core to community practice - holistic care, patient centred care, continuity of care, preventative care and patient education.
Students comment regularly that they have never experienced doctor/patient relationships in the same way in a hospital setting, seeing the GPs in their many roles as physician, counsellor, mentor, holder of individual, family and community knowledge and as a valued friend.
During their final medical years a student learns how a text book description of diseases and disease management is translated into a patient living with a disorder. This may not readily be learned from a hospital setting where the patient is safely tucked under a white sheet. Social determinants of health seen from the end of a hospital bed are purely theoretical but in general practice they are real, they are seen.
It is essential that any medical training programs support interns to be confident and competent clinicians, and this competency has become the measure of the effectiveness of medical training. There are two programs which assess intern competency in Australia - one involves assessment by hospital staff, the other interns assessing their own preparedness to practice. In both arenas the University of Wollongong program scores highly.
It interested me to investigate whether interns perceived their time in general practice had contributed to their competency and what factors particular to the longitudinal GP placements had contributed towards this. So I asked this question of 15 former students who had by then completed their internships.
Long term relationships with GP supervisors, practice staff and patients.
Pivotal to the GP clerkship working effectively are the relationships the student forms with supervising clinicians. The GP supervisor gives one-on-one supervision. Over time a sense of mutual respect and trust develops, with the supervisor becoming aware of the student’s strengths and learning needs and supporting them to develop increasing levels of clinical competency.
In the words of one student, “I think one of the best parts of it is that you form quite good relationships with senior clinicians. You identify different role models and mentors, doing it this way you are a lot closer to them”
While there are times these relationships have not been ideal,. this has been a rare and has usually been quite resolvable. We have learned to better match student with practice and to better support both student and supervisor in this situation. As we get to know our students we are in a better position to anticipate issues that may arise.
Students are given long appointments with patients and talk of the importance of their longitudinal relationships. Some patients make a deliberate choice to see the student regularly. One student guided her patient through palliative care, another saw a depressed patient fortnightly over the year. This gives the students insight into disease progression, response to long term treatment and to the patient experience of living with a disorder.
Since these students are postgraduates, many with previous health care experience, their input can be very valuable, for instance a current student who is a speech pathologist with a special interest in autism, with another being a dietician with an interest in obesity.
As well as relationships with their supervisors and patients, students developed a sense of team work with in the practice and within the community. Having an in-depth knowledge of how clinical care and support are provided in the community assisted them as interns in effective discharge planning.
Said one, “When writing discharge summaries, while other interns just cut and pasted from the notes, I really put an effort into giving the GP the information they needed and indicated what support we recommended the patient required in the community.”
Developing clinical skills
Both in general practice and small hospital EDs students had many opportunities to be the first to review patients with undifferentiated disease and to practice their clinical reasoning skills. They became competent at recognising and managing the commonly presenting cases they later managed as interns.
Feedback has included -
“One of the greatest assets of the longitudinal placement is the ability to do parallel consulting. Once my supervisors became aware of my skill level and my learning needs they allowed me to examine and obtain histories from patients and to initiate management plans, of course with their review. That ability to go through the process independently is really where you learn.”
They became proficient at common procedural skills which reduced some of the stress suffered by many of us as interns.
“I spent a lot of time in emergency and had a lot of independence there. I guess we were given more responsibility as students than we would have been given elsewhere. My first term as an intern was in emergency and I just felt very well prepared.”
The students really appreciated the autonomy they were given in parallel consulting and felt that more than anything this helped them to develop as independent learners, to develop their clinical skills and gave them a sense of professional identity.
“It made me be more of an independent thinker, I remember feeling very out of my depth and out of my comfort zone. Having a patient in front of you and having to deal with their problems and decide how to manage their problems, prepared me quite well for internship. It is such a huge step acting independently.”
It is vital to the program that in their supervising of students they are not completely out of their depth or overwhelmed. As we have all become more experienced we have learned to recognise that each student will progress at their own pace and that some will be slower to take on clinical responsibility, while others at times need holding back.
Developing professionalism and identity.
In parallel consulting and often in the smaller EDs where there are no junior medical staff students often “act-up” under safe and supervised conditions. The students respond to this level of responsibility by taking on a professional role. They are made to feel a valued part of the team.
“I was treated as though I was already a doctor and that was a huge responsibility I had to take seriously.”
Advantages of rural training
The consensus view was that training rurally was an excellent way to learn medicine for a variety of reasons, including close and continuing relationships with clinicians, less competition for access to patients, and the opportunity to extend their clinical skills by “acting-up” in the absence of junior medical staff.
Various studies in different parts of the world have confirmed that longitudinal placements in rural genera practice provide an effective training ground for medical students. One young doctor said he now sees “medical students coming through and teaches them , and can really see the difference in the abilities of students who train rurally.”
He felt that “their clinical skills, communication skills, and patient rapport ware superior”.
GP supervisor feedback
It is not a small undertaking to host medical students on longitudinal placements and I feel very grateful for those who have done so. Many of our local practices are in their eighth year of supervising students on these longitudinal placements. For the most part, the GPs involved have gained great satisfaction from supporting their students to evolve from student to junior doctor and hearing of their later progress on their medical careers. It has been particularly gratifying to know that some of these students have returned to participate in the intern program in Lismore and Tweed, and others to progress to the NCGPT program.
Others are working rurally and regionally in a variety of specialties across the country. One young doctor I interviewed has completed her GP training and happily works as a rural GP in the practice she trained in as a student - much to the joy of her GP supervisor.
For my own part, it has been a wonderful learning curve towards the end of my career to move from clinician to teacher. I have met and worked with some very lovely young men and women who give me hope as I watch them blossom and grow into the doctors of our future.
Jane Barker is a Northern Rivers GP and coordinator of student placement at the University Centre for Rural Health.