Professionals' perspectives on factors affecting GP trainees' patient mix: Results from an interview and focus group study among professionals working in Dutch general practice

Abstract

Introduction Seeing and treating patients in daily practice forms the basis of general practitioner (GP) training. However, the types of patients seen by GP trainees do not always match trainees' educational needs. Knowledge about factors that shape the mix of patient types is limited, especially with regard to the role of the professionals who work in the GP practice. Aim We investigated factors affecting the mix of patients seen by GP trainees from the perspective of professionals. Design and setting This qualitative study involved GP trainees, GP supervisors, medical receptionists and nurse practitioners affiliated with a GP Specialty Training Institute in the Netherlands. Methods Twelve focus groups and seven interviews with 73 participants were held. Data collection and analysis were iterative, using thematic analysis with a constant comparison methodology. Results The characteristics of patients' health problems and the bond between the doctor and patient are important determinants of GP trainees' patient mix. Because trainees have not yet developed bonds with patients, they are less likely to see patients with complex health problems. However, trainees can deliberately influence their patient mix by paying purposeful attention to bonding with patients and by gaining professional trust through focused engagement with their colleagues. Conclusion Trainees' patient mix is affected by various factors. Trainees and team members can take steps to ensure that this mix matches trainees' educational needs, but their success depends on the interaction between trainees' behaviour, the attitudes of team members and the context. The findings show how the mix of patients seen by trainees can be influenced to become more trainee centred and learning oriented. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.

Keywords

Author Keywords

Qualitative research Primary care MEDICAL EDUCATION & TRAINING

Index Keywords

learning adult attitude to health female human male medical education Health Knowledge, Attitudes, Practice Humans Article interview Thematic analysis qualitative research education general practice general practitioner Interviews as Topic controlled study middle aged professional standard major clinical study information processing health personnel attitude Attitude of Health Personnel Focus Groups Education, Medical, Graduate nurse practitioner trust Netherlands Professional Role attention medical receptionist

Author Affiliations

Department of General Practice, Universiteit van Amsterdam, Amsterdam, Noord-Holland, Netherlands

Department of Public Health and Primary Care, Leids Universitair Medisch Centrum, Leiden, Zuid-Holland, Netherlands

Funding & Acknowledgements

ZonMw

Grant: 839130001

The mix of patients seen by GP trainees should offer trainees the opportunities they need to develop competencies and to acquire skills. This study reveals that trainees’ patient mix is affected by many entangled factors, but that trainees can take a central role in influencing their patient mix, both direct and indirectly. These findings have some implications for practice. First, trainees should be aware that they can directly influence their own patient mix. Following our results, we recommend enlarging trainees’ knowledge of the effects of the doctor-patient relationship and of ways in which they may speed up the bonding between themselves and their patients. For example, trainees can be taught to deliberately make social house visits, contact patients after their visit to the hospital or arrange that all follow-up visits will be with the trainee. Second, trainees should be encouraged to arrange with their supervisor or the nurse practitioner to transfer some patients to the trainee’s care. However, trainees and their supervisors should be informed that with this transfer, a transfer of trust must also take place. Seeing a patient together with the trainee and supervisors/nurse practitioner or stressing the trainee’s qualities may help ensure that patients receive the same quality of care with the trainee as they do with their former doctor. Furthermore, trainees and supervisors should be informed that relationships between trainees and the team members of a practice indirectly influence trainees’ patient mix. Therefore, trainees should be instructed to maintain good relationships by showing keenness, involving other team members in their learning and conversing with the medical receptionist about their experiences during consultations. Moreover, supervisors and nurse practitioners should be aware that their own perceptions and beliefs about patient care influence the patients a trainee sees. We recommend starting the training year with a discussion between the trainee, supervisor and other team members about these beliefs and the trainee’s expectations. The above-mentioned recommendations of this study, together with the results a subsequent study on patients’ perspectives, will be used to design an educational intervention to enhance GP trainees’ patient mix. This intervention study will lead to even more concrete and substantiated recommendations for trainees, supervisors and GP training programme directors. The authors wish to thank all participants who were willing to share their thoughts about trainees’ patient mix, as well as the staff of the GP specialty training of the Amsterdam UMC (University of Amsterdam) who helped us with the organisation of the focus groups and interviews. Contributors SdB, MV and NvD designed the study. SdB, SvR and MV performed the interviews and analysis with support from NvD and AK. All authors discussed the results. SdB wrote the manuscript with input from all authors. Funding This work is funded by a grant from ZonMW (grant number: 839130001). Competing interests None declared. Patient consent for publication Not required. Ethics approval Dutch Association for Medical Education (file number 630). Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available upon reasonable request.

ZonMw

The mix of patients seen by GP trainees should offer trainees the opportunities they need to develop competencies and to acquire skills. This study reveals that trainees’ patient mix is affected by many entangled factors, but that trainees can take a central role in influencing their patient mix, both direct and indirectly. These findings have some implications for practice. First, trainees should be aware that they can directly influence their own patient mix. Following our results, we recommend enlarging trainees’ knowledge of the effects of the doctor-patient relationship and of ways in which they may speed up the bonding between themselves and their patients. For example, trainees can be taught to deliberately make social house visits, contact patients after their visit to the hospital or arrange that all follow-up visits will be with the trainee. Second, trainees should be encouraged to arrange with their supervisor or the nurse practitioner to transfer some patients to the trainee’s care. However, trainees and their supervisors should be informed that with this transfer, a transfer of trust must also take place. Seeing a patient together with the trainee and supervisors/nurse practitioner or stressing the trainee’s qualities may help ensure that patients receive the same quality of care with the trainee as they do with their former doctor. Furthermore, trainees and supervisors should be informed that relationships between trainees and the team members of a practice indirectly influence trainees’ patient mix. Therefore, trainees should be instructed to maintain good relationships by showing keenness, involving other team members in their learning and conversing with the medical receptionist about their experiences during consultations. Moreover, supervisors and nurse practitioners should be aware that their own perceptions and beliefs about patient care influence the patients a trainee sees. We recommend starting the training year with a discussion between the trainee, supervisor and other team members about these beliefs and the trainee’s expectations. The above-mentioned recommendations of this study, together with the results a subsequent study on patients’ perspectives, will be used to design an educational intervention to enhance GP trainees’ patient mix. This intervention study will lead to even more concrete and substantiated recommendations for trainees, supervisors and GP training programme directors. The authors wish to thank all participants who were willing to share their thoughts about trainees’ patient mix, as well as the staff of the GP specialty training of the Amsterdam UMC (University of Amsterdam) who helped us with the organisation of the focus groups and interviews. Contributors SdB, MV and NvD designed the study. SdB, SvR and MV performed the interviews and analysis with support from NvD and AK. All authors discussed the results. SdB wrote the manuscript with input from all authors. Funding This work is funded by a grant from ZonMW (grant number: 839130001). Competing interests None declared. Patient consent for publication Not required. Ethics approval Dutch Association for Medical Education (file number 630). Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available upon reasonable request.

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Professionals' perspectives on factors affecting GP trainees' patient mix: Results from an interview and focus group study among professionals working in Dutch general practice

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