Evaluating the impact of a teaching course for GP speciality trainees

ABSTRACT

Introduction

Near-peer teaching offers mutual benefits for clinical trainees and the students they teach. However, General Practice Speciality Trainees (GPSTs) are typically less involved in community-based teaching than their hospital-based peers and often do so without formal pedagogical training. This study details the immediate and longer-term evaluation of a teaching skills course delivered to final year GPSTs. It addresses a gap within existing near-peer literature which, although extensive, is predominantly hospital-based and limited to short-term outcomes.

Methods

The course was designed and delivered to all local final year GPST schemes. Pre- and post-course questionnaires scoring confidence, comfort, and understanding of teaching roles were analysed across two years’ delivery. Furthermore, individual interviews of participants 4–6 months after attendance were thematically analysed to explore how GPSTs translated course content into practice.

Results

GPSTs reported a decline in their teaching activities as they embarked on their final year of GP teaching. Immediate post-course teaching-related confidence and knowledge scores increased. However, follow-up interviews revealed that GPSTs’ initial enthusiasm was short-lived and outweighed by competing demands within an intensive short-duration training scheme. They expressed concerns about their own learner status as they themselves developed competency in a vast and varied speciality, and cited a lack of support from their trainers.

Conclusions

Teaching skill courses alone are insufficient to address the ongoing challenges of enhancing the teaching role of GPSTs. Further work is now needed to explore multi-level interventions to promote the role of GPSTs as near-peer teachers to harness the mutual benefits to all involved.

KEYWORDS:

• near-peer teaching
• teaching skills
• GP trainees

Introduction

Teaching others is an integral part of a doctor’s role [1] with postgraduate curricula highlighting the cultivation of this role throughout clinical training. Trainee doctors generally enjoy their roles as clinical teachers, with near-peer teaching serving as catalyst for learning for both trainee (teaching others being a powerful driver of learning) and the learner (teaching is more closely tailored to their learning needs and undertaken within socially-conducive learning environments) [2]. However barriers exist to impede trainees’ development as clinical teachers including lack of protected time in which to teach, competing clinical duties and lack of formal teaching skills training [3]. Furthermore, the extent to which trainees engage in teaching roles varies between different speciality training programmes with UK General Practice Speciality Trainees (GPSTs) typically less involved compared to their peers in hospital-based specialities [4]. This discrepancy is of particular concern given the shifting landscape of both patient care and undergraduate education towards community settings, coupled with a planned expansion of UK medical student places, necessitating a greater reliance of community-based educators. Previous work has revealed that although GPSTs welcome the opportunity to become more involved in teaching, they often do so without formal pedagogical training [5].

This study describes findings from a multi-level evaluation of a teaching skills course delivered to final year GPSTs. It not only captures immediate post-course views from participants but also explores, through longer term follow-up, what impact the course had on their onward teaching activities. The findings help address a gap within existing near-peer literature which, although extensive, is predominantly hospital-based and limited to short-term outcomes.

Methods

The teaching course (‘PRIME-GPST’) was designed as a modification of our existing GP tutor development course and refined through scoping workshops with experienced GP trainers. The existing tutor course focussed primarily on provision of core teaching skills including enquiry-based learning principles and approaches to feedback and assessment, including both end-of-placement sign-off and an overview of the students’ wider assessment requirements. However, our prior review of the literature, and feedback obtained from the scoping workshops, both highlighted that GPSTs often do not recognise the reason why becoming involved in teaching as a trainee is an important professional development area and as such can view this as additional workload burden that competes with their other learning needs. As such, the existing tutor course was modified to include a specific workshop that encouraged trainees to ‘buy-in’ to the idea of taking on teaching through interactive tasks that helped them identify the myriad benefits of serving as a near-peer teacher. Subsequently, two half-day workshops with four workshops (two per day) were created with course content and intended learning outcomes as described in Figure 1. Each workshop was 90 minutes in length and used a hybrid of brief presentations and interactive small group work tasks such as discuss and report, and role-play scenarios. Following local postgraduate training body approval, the course was annually integrated as part of the weekly time-protected scheduled teaching days for all nine GPST3 training programmes in the locality. Through integrating the course in this way, all GPST3s in these schemes were expected to attend (excepting annual or sick leave) in line with general attendance requirements for their scheduled weekly teaching.

Figure 1. Course content and intended learning outcomes.

At the very start of each course, all participants were asked to complete a ten-Likert item agreement scale to establish their baseline views and prior teaching activity context. The first five items were subsequently re-scored post course.

Kirkpatrick’s evaluation model was adopted to assess the project’s success [6]. Evaluation at the first level was conducted using immediate on-the-day participant questionnaires combining both five-point Likert-type scale responses and free-text comments. Scale items revisited each workshop’s ILOs with participants scoring their changes in understanding of each workshop topic (1 indicating little understanding through to 5 indicating full understanding). Additionally, participants completed ‘commitment to change’ statements, indicating intended future actions to increase their teaching role [7]. Level two evaluation utilised pre- and post-course Likert-scale responses on a multi-item questionnaire using a 5-point agreement scale (strongly disagree through to strongly agree). Analysis identified both baseline views and changes following course attendance. Finally, evaluation at the uppermost Kirkpatrick levels was undertaken through follow-up individual interviews of course participants four to six months following attendance. Using a semi-structured topic guide, participants’ engagement with teaching activities following the course was explored. Specifically, participants’ ‘commitment to change’ statements were revisited to explore barriers and enablers to their onward teaching involvement. All interviews were recorded, transcribed with identifiers removed and inductively analysed using a reflective-thematic approach both within and across transcripts to look for significant or recurring concepts [8]. Ethical approval was granted by the University of Manchester.

Results

Data was obtained for 360 participants who attended the course across two academic years in the 9 local GP training schemes. Baseline views were completed by all participants and are reported in Figure 2.

Figure 2. Participant baseline views.

Level 1

All 360 participants also completed pre-course and immediate post-course evaluation questionnaires. This required them to score their level of understanding on a 5 point scale (1 = little/no understanding to 5= complete understanding) for each of the four workshops – to inform participant scoring, they were presented with the workshop ILOs within the questionnaire. Participant responses demonstrated statistically significant rises in mean understanding scores for each workshop (Table 1). Participants were additionally asked to score two additional Likert-agreement scales relating to course delivery with 100% of participants agreeing or strongly agreeing that the course met expected aims and was well organised and delivered. The penultimate part of the immediate post-course questionnaire asked trainees to indicate their preferred scheduling of delivery of the course with six options – ST3/ST2/ST1 and each with first half of training year and latter half of training year. More than 75% of trainees indicated they would have preferred the teaching course to have been delivered earlier in their training (with an expressed preference for delivery at the start of their second year of GP training).

Table 1. Changes in participants’ topic understanding pre- and post-workshop

Workshop	Pre-workshop understanding mean score (/5)	Post-workshop understanding mean score (/5)
Getting involved in teaching	3.39	4.25 *
Enquiry-based learning	3.25	4.36 *
Feedback	3.00	4.59 *
Assessment	3.13	4.37 *

*two-tailed p < 0.0001.

Lastly, participants had the option to provide free-text comments. This was only completed by 37 respondents. The majority of these were positive with participants suggesting the course encouraged them to develop a ‘positive approach to teaching’ inspiring them to be ‘more proactive’ and ‘motivated to get involved in teaching’. Five comments were less positive and highlighted in some cases that respondents had not been informed in advance what the course was about by their local training scheme, whilst two comments suggested a preference for using the allocated time to focus on clinical learning topics.

Level 2

As part of the immediate-post-course evaluation, participants were asked to re-score the first 5 items of the previously mentioned baseline-view question-set. Not all participants fully completed this section and therefore data was obtained from 179 participants (Table 2).

Table 2. Changes in participants’ views pre- and post-workshop

Statement	Pre-Course Mean (/5)	Post-Course Mean (/5)	Independent-Samples Krusal-Wallis Test Significance
I believe teaching others should be one of the core roles of a GP trainee	3.9	4.1	0.002
I am confident in my teaching ability	3.2	3.8	<0.0001
I am comfortable teaching students	3.2	3.9	0.003
I understand what is expected of me with regards to developing my teaching role	3.1	3.8	<0.0001
I am able to integrate teaching activities with my clinical work during ST3	3.5	3.7	0.056

Level 3 and 4

Ten GPSTs consented to follow-up interviews (4 males, 6 females) conducted between four to six months after course participation. Key themes were generated and categorised under positive motivators and barriers to trainee engagement with teaching. Exemplar quotes for each theme are provided in Table 3.

Table 3. Exemplar quotes for interview themes

Category	Theme	Exemplar quotes
Positive motivators to trainee engagement	Participation in the course initially generates enthusiasm for teaching	‘Initially I didn’t know what it [the course] meant, or why we had to do it, and it just felt like something that was compulsory that you had to do, another tickbox exercise more than anything. After the second day, I thought “actually this is something I can actually use, and start to use in practice”’ Interview 6 “I just thought: right I need to find some medical students to try and practice this on them … it’s given me the go ahead to actively seek out teaching. If medical students are in the practice then I’ll try and lend a hand teaching them. Interview 5 ‘Whilst I haven’t had a chance to do much with the training so far, it has made me realise that I want to do quite a bit of teaching once I CCT [complete training]’ Interview 8 ‘It’s made me realise that I would want my future roles post-CCT to have an element of teaching with in it. so yeh its been helpful that way’ Interview 2
	The course helped generate solutions to potential barriers	‘I thought the discussion around blockages to teaching was actually really useful thing to consider, because it’s one of those things that we all faced but didn’t know how to overcome’ Interview 8 ‘I think there’s a general anxiety around being observed, either by a student or anyone really … I think that [aspect] was tackled fairly well’ Interview 2
	By attending PRIME-GPST, participants felt more confident in the principles and practice of teaching	‘I really appreciated going through the structure of the student placements and what they are supposed to be doing in different years … looking at it as a whole that was quite helpful because everyone’s uni has been quite different’ Interview 3 ‘I feel a lot more equipped than I did before. Before I wouldn’t have been able to give constructive feedback or even encourage medical students into coming to GP and trying to learn something – I don’t think I would be able to develop a session, but since doing the training I’ve developed my own sessions with the medical students and they’ve found that really helpful and they’ve given that feedback back to the trainer as well’. Interview 7
	Understanding peers’ experiences and degree of teaching involvement triggered their own teaching interests	‘It’s made me think about it more consciously, that I’m missing out on something that a lot of the other trainees do already do – they do undergrad teaching, and I don’t do any. I actually wonder if it’s a sort of a spot on my CV that I need to develop, and that’s made me realise that I need to make more of the opportunities that I’ve got in practice’. Interview 2
	Formal skills training was seen to make teaching activities permissible	‘It gave me the sense I now had a qualification to say I could do it properly, but already had been supervising medical students just ad hoc, but it just gave me the go ahead to say that I could take on medical students now’. Interview 4 ‘Even thought it was a two day course it was still a … in a way it gave me permission to move forward from there and say “you’ve got PRIME”, even though I may have been teaching beforehand it was still a confidence booster’. Interview 9
	Positive support from the GPST’s trainer helped further motivate interest in teaching	‘I just informed them [my trainer] I was interested in teaching medical students and I had now done the PRIME course. and yeh they were very receptive to me helping supervise the medical students and teaching them’ Interview 4 ‘My trainer is very keen to encourage me to get involved in teaching … he’s always encouraged me to go and do formal sessions. I think he was aware of the pressures in ST3, and wasn’t going to push me to get involved unless I initiated things, but as soon as I’ve shown interest in things he was very enthusiastic himself and keen to assist’. Interview 6
Barriers to trainee engagement	The initially generated enthusiasm for taking on teaching roles quickly waned	‘Straight after the course, I was probably quite enthusiastic about thinking that there were some changes from what I remember from medical school, and I thought “oh well that sounds good”, and was enthusiastic about doing some teaching. That was straight after the course, but then that quickly changed as time went on’. Interview 3 ‘I spent the rest of the year getting through ST3 [final year of training]. I was at a training practice where we have medical students, so I remained keen to, and probably had more of an awareness of where they were in their training and what they were hoping to get out of the placement. But, but with the pressures of ST3, no I didn’t particularly take on any other roles since the course’ Interview 8
	Trainees cited lack of opportunities to put into practice their newly developed teaching skills	‘Coming out of it I thought “I’ll enquire about what I can do” which I did try and take forward, speaking to my supervisor, but at that point just after we’d done the course I started in general practice rather than my hospital rotations, and it was … and there weren’t any medical students at my practice so I kind of … stopped thinking about it’ Interview 3 ‘So we had students after Christmas, but they already had protected teaching sessions with their own supervising GP. And even before or after the course that was still the same, so the opportunity to teach them was there, hadn’t changed, it was still trying to squeeze in an extra session, if they had time before our time here and there around the working week’. Interview 9
	Competing demands relegated teaching activities when priority setting	‘You’ve got to have a think about how you’re going to fit in medical student teaching to your busy day … how’re you actually going to facilitate that with your practice to make it work?’ Interview 4 “With our exams coming up … it kind of puts you off, ‘cause you know the way GP is that it’ll be your own time that’ll have to be used rather than the GP practice time. So it [the course] made me enthusiastic [about teaching] but probably after I’ve qualified as a GP. Interview 3 “I think it can easily be something that’s kind of pushed out, because your immediate priority is things like doing your day job and doing it safely and getting the paperwork done and not being there ‘til seven. And then you’ve got your portfolio and exams so by the time you get down to things that are purely voluntary like teaching it’s not a priority – I might not say voluntary but you’re not gonna get struck off if you don’t do your teaching” Interview 2
	GPSTs reflected that their own learner status and evolving clinical knowledge base as they themselves developed competency in a vast and varied speciality could negatively impact their teaching	‘It’s different teaching in GP than when we were in hospital. In hospital we did specific clinical rotations and I felt confident in doing the day to day tasks on the wards so I was quite happy having a student shadow me or doing bedside teaching on set topics. But in GP we can see everything and anything and so if I have a student sitting in … I myself wouldn’t know how to manage some of the patients … I’m not sure how useful that would be for a student who was with me versus had they been with one of the GP supervisors. Also our training scheme is much shorter than hospital specialities which I imagine impacts on how willing some of us are to teach in this last year of training’ Interview 2 ‘I think there’s a general anxiety around being observed, either by a student or anyone really … I would feel quite uncomfortable having a student with me when at the moment I may not be sure myself what I am doing with a patient until I have discussed it with my supervisor. There’s a lot of pressure because you don’t want to waste people’s time, and even if they’re just medical students, they’re not just medical students – they’re students that are going to be your future colleagues, so you don’t want to waste their time, so it is quite daunting and it is a lot of pressure because you want to do the best for them’.” Interview 4
	Lack of support from GP trainers hindered involvement in teaching activities	‘I’ve kind of made sounds about it [my interest in teaching] to my trainer but I think the answer is that I could use my private study time to do it … I can see from their point of view – they need me for the clinical sessions. But it just doesn’t make it easy when you’ve got those pressures’. Interview 5 ‘She [my trainer] knew there was teaching course, I think from previous years. She wasn’t 100% sure what it entailed, how many days it would be or what it would mean after the course. So as a result we didn’t really discuss any plans or what I would want to do differently having attended the course’ Interview 6

Discussion

Previous studies exploring the role of the GPST as a clinical teacher have indicated that GPSTs desire formalised teaching skills training as a way of encouraging increased involvement [9,10]. Our highly positive immediate post-course course feedback initially suggested that the efforts invested in designing and delivering such training was indeed worthwhile. The three skill-based workshops, exploring EBL, Feedback and Assessment, were all highly-rated with participants reporting increased confidence, comfort and understanding of their teaching role and as a result, teaching was seen to become permissible and expected roles. Additionally, the course inspired participants to pursue teaching roles in their future General Practice career after completing training.

However, despite such skill provision this work also highlights GPSTs’ concerns and challenges in how the expectation for teaching involvement is implemented in practice during their final year of training. Although 78% of course participants acknowledged the potential benefits of their teaching contributions to student learners, only 23% agreed that teaching was of one of their roles as a final year GPST. These findings highlight a substantial missed opportunity to harness the educational benefits for both trainees and student learners generated from near-peer teaching activities. The results also substantiate concerns that, paradoxically, GPSTs tend to decrease their teaching role as they progress through training with over two thirds of participants reducing teaching involvement as a final year GPST compared with their prior two years of hospital-based rotations. The observed disparity between these contexts can be ascribed to variations in cultural values and expectations within each setting. Whilst teaching involvement is typically the norm for trainees in hospital rotations, the GPST role is often restricted to being a learner within hierarchical structures that restrict their development as teachers [11]. This is particularly important given that trainees often serve as significant career role-models for medical students [12]. As such, increasing the opportunities for medical students to interact with GP trainees could help address ongoing UK GP workforce concerns.

Cognisant that the existing literature in this area has previously highlighted such challenges in translating skill provision into practice, the course incorporated a specific ‘getting involved in teaching’ workshop to help GPSTs explore ways to integrate teaching within their clinical workload and equip them with the confidence to negotiate with their trainers opportunities to teach within the practice setting. This workshop generated statistically significant rises in self-reported topic understanding and later interviews revealed that the peer-discussions served as helpful self-reflective stimulus to compare participants’ own level of teaching against cohort patterns. However, post-course questionnaires highlighted that this improved understanding was not accompanied by an improved degree of confidence with GPSTs continuing to express concerns about their ability to successfully integrate teaching activities in the remainder of their final training year. These apprehensions were subsequently borne out through follow-up interviews, which revealed that many did indeed struggle to put their newly developed teaching skills into practice. While instances of motivating factors for teaching involvement were cited, these tended to be short-lived and were outweighed by multiple barriers to engagement.

These barriers can be considered using the COM-B behaviour change framework which highlights three key aspects that drive behaviour, namely capability, opportunity and motivation [13]. Initially, capability was enhanced, as evidenced by aforementioned improvements in teaching-related confidence, comfort and knowledge scores. However, interviews revealed that GPSTs’ own learner status made them question their ability to deliver effective community-based clinic teaching, fearing it might be viewed by students as a poor educational experience. These concerns stemmed from participants’ own learning journey as they themselves became accustomed to managing uncertainty, complexity and the vast breadth of undifferentiated presentations across multiple clinical specialities characteristic of GP presentations, all within a short training scheme of which only 18 months is spent in primary care. Additional factors diminishing motivation to teach included competing demands such as impending exams, portfolio and workplace assessment requirements, and busy clinical work patterns. Thirdly, the limited opportunities to put their teaching skills into practice, whether due to a lack of other learners within their training practice or reluctance from their trainers to provide time-protected teaching opportunities, further impeded their ability to develop their teaching role. This contrasts with hospital settings that typically take many medical students and thus provides trainees numerous opportunities to engage in opportunistic or planned teaching encounters. Collectively these factors further help explain why GPSTs reported a reduction in teaching activities as they progressed into their final year of training.

This study was strengthened through the combined use of immediate and longer-term evaluative methods using a large participant dataset across two years’ delivery. However, there are recognised limitations to the work. Level 1 and 2 data arises from self-reported responses and thus may not fully capture immediate post-course impact. Additionally, the level 1 data reporting perceived changes in understanding for each workshop was asked at overall workshop level. Inquiry using a more granular inspection of change within specific ILOs may have revealed more nuanced findings. This work also acknowledges that those who agreed to take part in the follow-up interviews may have been self-selecting group that may not be representative of the wider GPST final year cohort. Lastly, whilst the focus of this evaluation was from the GPST perspective, additional triangulation with the GP trainers for participants could offer valuable further insight to understand the course’s full impact.

This work highlights that teaching skill development through formal training, whilst clearly important, is insufficient on its own to address the ongoing challenges of involving GPSTs within teaching activities, particularly in the demanding final year of training. Potential additional interventions to further address the ongoing underutilisation of GPSTs as clinical teachers have been identified from the findings and are described in Table 4 as aligned to the COM-B framework. Further work is now needed to deliver and evaluate such potential solutions to fully promote the role of GPSTs as near-peer teachers to harness the mutual benefits to all involved.

Table 4. Potential interventions to promote the development of GPSTs as teachers

COM-B Element	Potential interventions to promote the development of GPSTs as teacher
Capability	Continue roll out of teaching skills training – exploring the possibility of multiple shorter longitudinal delivery over one-off delivery models
	Deliver training earlier in training – potentially at the start of the second year of GP training, as suggested by participants, to foster earlier engagement and establish teaching role expectations
Opportunity	Work with GP trainers to secure their commitment in encouraging their trainees’ teaching role development by highlighting the important mutual benefits
	Encourage GP trainers to provide teaching opportunities within the practice – making teaching the norm for community-based trainees in alignment with their hospital-based peers
	Create external opportunities (for example at local medical schools) for GPSTs to undertake teaching activities – helpful for those trainees who do not have other learners within their training practice
Motivation	Ensure teaching does not become a burden, through addressing competing demands such as providing protected time to teach/implementing blocked appointment slots
	Engage key stakeholders to highlight the benefits to GPSTs in developing their teaching role – including GP trainers, local postgraduate training bodies and national college curricula

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Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.