1
Higher Professional Education Courses in the United Kingdom SUMMARY The need for higher professional education courses has been well established by young principals, medical educationalists and the Royal College of General Practitioners (RCGPR 1985a, 1987 and 1990; Regional Advisers, 1989). In recent years there has been an increase in their development. However there is still a small number catering for a very small group ofpotential learners. These courses have often been seen as an extension of vocational training. Seven such courses were identified and evaluated during this project. The method and the results of the evaluation are presented. The development of higher professional education courses needs to be tailored to particular local needs and any central planning can be stifling. In our project there was often inadequate organizational and financial support available. The courses proved to be demanding for the participants in terms of time and required motivation. Despite this, attendance was good. Much of the content of the courses laid emphasis on practice management, human behaviour, and medicine and society, which reflected the perceived needs of both organizers and participants. Where formative evaluation of the courses was carried out, this appeared to have an important effect on course development. However fewer than 50% of the participants were involved to any extent in any planning of the courses, which is clearly contrary to the recognized principles of adult or self-directed learning (Brookfield, 1986). Despite this, participants as a whole appreciated the courses and the effect these had on their work, a large proportion reporting a significant change in cognitive and affective areas of learning. Recommendations are made for future organizers of higher professional education courses.
INTRODUCTION "If the licence to practice meant the completion of his education, how sad it would be for the practitioner, how distressing to his patients! More clearly than any other, the physician should illustrate the truth of Plato's saying that education is a life-long process" (Osler, 1900).
DESPITE Osler's pronouncement ninety years ago, continuing medical education (CME) programmes are a relatively recent phenomenon in British general practice. They emerged following the Nuffield Provincial Hospitals Trust Conference held in 1961 (NPHT, 1962) and since that time continuing medical education has progressed rapidly. With the emergence of the Government's white paper on the National Health Service (Secretaries of State, 1989) and the new contract (Health Departments, 1989) the indications are that it is likely to change even more dramatically in the next few years not only in the design of programmes but also in the needs of general practitioners and their commitment to it. The history of vocational training for general practice has been well documented (Horder and Swift, 1979; Hasler, 1989). The need for special postgraduate training for general practice may have been recognized as long ago as 1884 (National Association of General Practitioners in Medicine, Surgery and Midwifery, 1845). Vocational training was introduced almost thirty years ago and became mandatory for NHS practice in 1981. However, despite this many trainees still find themselves ill prepared for their new practices whose standards and priorities may differ from their training practices. Although vocational training is for three years, the original recommendation from the College of General Practitioners (1966) and the Royal Commission on Medical Education (Todd Report, 1968) was for a fiveyear period of training for general practice, two years of
which was to be in general practice and three years in hospital posts. In some European countries a voluntary five-year programme for training exists (Horder, 1988). It is therefore perhaps not surprising that demands have been made for a further period of professional training for young principals (RCGP, 1985a, 1987). The aims and objectives of vocational training have been stated (RCGP, 1972; Second European Conference, 1974; RCGP, 1978; Oxford Region, 1986). As technology and knowledge have increased over the past two decades, the problems of coping with a "hypertrophied curriculum" (Abrahamson, 1978) in a limited training period have mounted. Despite attempts to ensure that the training is comprehensive, it is rarely possible for the trainee to be fully prepared for every situation that he or she will encounter in practice. Experience in the management of terminal care, for instance, may not be universal in the trainee year, and it has been shown that a trainee will see 75% of asthmatics and diabetics less than twice (Hasler, 1983; Adam and Oswald, 1985). Other aspects such as epidemiology, ethics, research, performance review, teamwork and practice management may not appear relevant or sufficiently important at the time. In a study asking trainers to rank the aims of general practice training, these same areas achieved lowest scores of importance (Tate and Pendleton, 1980). Continuing education should reflect changes in the way general practitioners practise and therefore it needs to be continuous. It is to be hoped that the trainee year will have been successful in encouraging and motivating the trainee to assume responsibility for his continuing education. But where can the young principal turn to for his continuing education? The Nuffield conference of 1961 under the chairmanship of the late Sir George Pickering made recommendations which led to the development of the modern
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postgraduate centre movement (NPHT, 1962). The formal programmes laid on by these centres for general practitioners were organized by hospital clinicians who had themselves decided on the content and format of the meetings, often without consulting the needs of the learners. The emergence of the general practitioner tutor (Berrington and Varnam, 1987) in many postgraduate centres has enabled the programmes to be more relevant to general practitioner needs. Despite this, attendance at lunchtime meetings is still depressingly low and has fallen since they ceased to become obligatory for seniority payments (Pickup et al., 1983a) and expenditure was cash-limited. This is bound to change with the impact of the new contract (Health Departments, 1989), which demands that all general practitioners attend 10 educational sessions per year to qualify for the postgraduate education allowance (PGEA). Self study has been a popular method amongst general practitioners as a method of continuing medical education (Scottish Council for Postgraduate Medical Education, 1979). Pickup et al. (1983a) found that general practitioners spent on average 140 hours per year on reading journals and periodicals. The University of Dundee has been instrumental in developing distance learning programmes for general practitioners and these have increased in popularity in recent years. Educational activities within the practice (Reiss et al., 1981; Owen et al., 1989), the presence of a trainee in the practice or the process of becoming a trainer have also been regarded as a valuable learning experience. However, general practitioner principals are usually unable to become trainers for at least three or sometimes five years. Young practitioner groups have gone some way to easing the situation but they can be too cosy for learning to take place and may lack effective leadership. However, their spontaneous formation throughout the country suggests a genuine need as perceived by the young general practitioner (Rhodes, 1983; Stott, 1984; Edwards et al., 1988). Support for higher professional training courses as a way of promoting the further development of the young principal has come from various sources. The Royal College of General Practitioners has supported their development (RCGP, 1985a, 1987 and 1990). Similarly the 1989 Conference of Local Medical Committees and the 1989 working party of the Regional and Associate Regional Advisers in General Practice (1989) have requested additional funding for their development. In several parts of the country higher professional education courses have begun to emerge (Courtenay et al., 1982; Parry and MacFarlane, 1983; MacInnes, 1987). Organized continuing education has traditionally been by Section 63 meetings in postgraduate centres, which have tended to be poorly attended. Research has indicated that this does not appear to be due to the content or methodology (Pickup et al., 1983b). Until fairly recently, medical education has been influenced by the traditional approach to learning, based on behavioural objectives. This demands that the course teacher should define observable behavioural objectives (cognitive, psychomotor or affective) and develop teaching methods to implement the desired learning, and assess the achievements in relation to the stated objectives. The main criticisms of this approach have been:
(a) practical: that to define and measure objectives in a number of areas which are especially relevant in general practice, for example attitudinal changes, is difficult. Furthermore to produce objectives for the whole course is time consuming, does not allow for discovery learning, and tends to produce trivial objectives. (b) theoretical: that a list of actions does not represent a structure of knowledge, as there are a number of different paths through any body of knowledge. Consequently any assessment may not be valid and the use of objectives does not cover all the interactions between student and teacher (Beard and Hartley, 1986). Recommendations have been made by researchers that more attention be paid to the theories of adult education. It has been suggested that courses need to be based upon a sound curriculum plan which follows a sequence of logical steps (Bandarnayake, 1985). In particular CME activities should be more self-directed and self-determined (Wood and Byrne, 1980; Stone et al., 1982; Bandarnayake, 1985; Horder et al., 1986; Branthwaite et al., 1988). A great deal of work has been carried out in recent years on adult education and the adult learner. The relatively new concept of andragogy has gained increasing acceptance amongst educators. Andragogy has four basic assumptions (Knowles, 1980): 1. That adults both desire and enact a tendency toward self-directedness 2. That adult experiences are a rich resource of learning 3. That adults are aware of specific learning needs generated by real life tasks or problems 4. That adults are competency-based learners in that they wish to apply newly acquired skills or knowledge; i.e. they are performance centred in their orientation to learning. Andragogy represents a model of learning consisting of a set of assumptions about the way adults learn. It can be contrasted with pedagogy, which implies a greater gradient of power and knowledge between educator and learner. The concept of andragogy helps adult educators to define their approach as being more collaborative and facilitative. At the centre of this theory is the concept of the self-directed learner. A self-directed learner is one who "with or without the help of others, identifies his or her learning needs, sets relevant feasible and measurable learning objectives; determines generally accepted standards or criteria which will be applied to assess whether learning has in fact occurred as planned; and finally formulates a coherent learning agreement or personal curriculum for the course" (Knowles, 1975). The benefits of self-directed learning are clearly that the needs of the individual are identified and will be matched to the objectives of the course. Self-directed learning encourages the pursuit of continuing education through the encouragement of autonomous learning (Hammond and Collins, 1987). Critics of Knowles' concepts have disputed his definition of adulthood and the development of selfdirectedness based on the attainment of a certain chronological age (Brookfield, 1986). Others have stressed the importance of viewing the adult and his propensity to self-directedness as a product of his society and
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culture (Fromm, 1942; Nottingham Andragogy Group, 1983). The courses should reflect the principles of andragogy and the following guidelines have been suggested (Brookfield, 1986): 1. Participation is voluntary and therefore must appeal to potential participants. 2. Respect among the participants for each other's worth needs to be established. The group facilitator needs to have adequate group leadership skills. 3. Facilitation is collaborative. Autonomy needs to be encouraged. Participants should be invited to participate in the design and implementation of the courses. 4. Kolb and Fry (1975) saw learning as a circular process of four stages in which Concrete Experience is followed by Reflection and Observation which leads to the formulation of Abstract Concepts and Generalizations which may be tested in Active Experimentation. This process needs to be continuous throughout the course. 5. Critical reflection should be encouraged. Increased awareness and the questioning of values, standards and morals will facilitate the process of personal and professional growth. 6. The aim should be to encourage the nurturing of the self-directed pro-active adult.
BACKGROUND TO STUDY The need for higher professional education courses has already been established (RCGP, 1985a, 1987 and 1990; Regional Advisers, 1989). The stimulus for this study arose from: 1. The lack of knowledge of the provision of such courses, their content and organization 2. The need to provide an evaluation of these courses and appraise their educational value 3. The need to discover whether CME activities follow the principles of adult education 4. The lack of a directive lead from any educational and political body in recognizing the specific learning needs of young principals and the need for protected
time. The aims of the study, which arose from these needs, were to examine higher professional education courses throughout the country and specifically: 1. 'l provide a descriptive documentary. We were interested in exploring their content, their design, their curricula and their methods of evaluation and assessment 2. lb find out to what extent they addressed the needs
of the participants and the institutions 3. 'b evaluate the courses against certain criteria, namely whether there was a need for such courses and to what extent principles of adult learning were adhered to
4. To examine the management of the courses. It seemed to us that a study of this nature had not been undertaken before and the information obtained might help future organizers in the setting up of such courses.
METHODS OF THE STUDY 1. Identification of courses For the purposes of this study we were prepared to look at any course which was aimed specifically at young principals and which was of at least one year's duration. A young principal was defined as a general practitioner with less than seven years' experience of general practice. A letter was sent to all the regional advisers in general practice, RCGP faculty secretaries, and heads of departments of general practice requesting any information on such courses. As a result of this enquiry seven courses were identified which fulfilled our criteria (Table 1). A brief synopsis of their content is given in Appendix 1. Table 1. Organizers and titles of courses.
Organizer North and West London Faculty of the Royal College of General Practitioners (NW London) British Postgraduate Medical Federation, University of London (BPMF) MSD Foundation (Scotland) Department of General Practice, Postgraduate Medical School, University of Exeter (Exeter) Department of General Practice and Community Medicine, University College Hospital (UCH) Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's Hospitals (Guy's) Oxford Regional Committee for Postgraduate Medical Education and Training; University Department of Public Health and Primary Care; Thames Valley Faculty, Royal College of General Practitioners (Oxford)
Title Higher Professional Education Course Advanced General Practice GP Now MSc in Health Care
Health for 2000: Changing Primary Care MSc in General Practice
Higher Professional Training Courses for General Practice
2. Data collection We decided to study all the courses and obtain data from all the course organizers and participants. Two groups of data were collected: descriptive (i.e. factual) and evaluative (i.e. qualitative), expressing mainly opinions and
perceptions. Three principal sources of data collection were used: questionnaires, interviews and documentary sources.
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Questionnaires Postal questionnaires were to be the principal method of data collection. The questionnaires were by design predominantly open ended. Such open-ended questions are considered to be indispensible for exploratory studies (Morris, 1987; Woodward, 1988). These elicited answers that were not constrained by previously determined criteria. This can be seen in question 9 in the questionnaire to the participants where the impact of the course on the practice and the participant was looked for (page 22). This 'goal free evaluation' (Scriven, 1972) allows the respondent to focus on what is perceived by him to be important, and often a personal dimension may emerge which may not have been anticipated by the survey designer or elicited by a more closed form of questionnaire. This applies especially to the affective aspects of development of 'personal growth', which is difficult to plan for yet is acknowledged by educationalists to be of fundamental importance. Analysis of open-ended questionnaires can, however, present problems. Despite this, only the responses to question 8 were discounted as these proved too difficult to interpret. Course organizers: The questionnaire which was sent to all the course organizers (Appendix 2) was designed to elicit descriptive data (a) about the course, such as frequency and duration of meetings, means of advertising and selection; (b) about the course organizers, such as number, support and training; (c) about curriculum planning, such as the design of the courses and sessions; (d) use of outside resources; and (e) aspects of adult learning such as participant involvement. Participants: Each participant was sent a questionnaire (Appendix 3) and non-responders were followed up with two reminders. The questionnaire was developed to elicit two types of data: (a) structural/descriptive relating mainly to participants and their practices; and (b) evaluative relating to their experience of the course and the perceived impact on their work and professional life. Aspects of adult learning were explored through questions on participation in planning the course and congruence between the course design and aims of participants, and the fulfilment of these aims. Interviews Course organizers: Semistructured interview schedules were constructed after receipt and preliminary analysis of the questionnaires to clarify some data such as reasons courses were started, content of certain sessions, and additional data such as costs of the courses, numbers completing them, attendances, problems experienced by course organizers in management of the courses, and methods of evaluation. All the course organizers were interviewed face to face, and these interviews extended over one hour. Interviews were hand and/or tape recorded and transcribed in three cases to verify the completeness and reliability of the manual recording. One of us (RGP) was invited to attend the meeting of the steering committee of the course This meeting extended over a two-hour period and provided useful information on the management problems associated with the course. Participants: The questionnaire was piloted during its development by using the questions as a basis for interviews with randomly selected participants to establish the
feasibility and validity of the questions. In two cases the interviews were tape recorded to check the reliability of the answers. Documentary evidence Documentary evidence concerning the courses such as advertisements, timetables, workbooks, and reading lists were obtained. These provided the necessary descriptive data about factors such as the content and structure of the courses and number of sessions. 3. Data presentation The data have been presented in the following sections: A. Structural data Information is provided about the course and the participants and their practices.
B. Evaluation of curriculum planning This has been presented after Harden (1986), who presented an educational model of progress from needs to management through 10 questions:
What are the needs? What are the aims and objectives? What content should be included? How should the content be organized? What educational strategies should be adopted? What teaching methods should be used? How should assessment be carried out? How should details of the curriculum be communicated? 9. What educational environment should be fostered? 10. How should the process be managed? 1. 2. 3. 4. 5. 6. 7. 8.
C. Outcomes Each of these three sections contains responses from both the participants and the course organizers. 4. Data analysis The data obtained from the respondents fall into two main groups:
Numerical Numerical data are presented in a raw format, such as number of partners, or have been derived from the answers, for example the cost of the course/participant/ year.
Verbal Verbal data are presented in three formats: * as free text, such as the title of the course to illustrate the range of answers, or to illustrate viewpoints where categorizations would have been difficult and not helpful * numerically, in the case of easily quantifiable verbal responses indicating simple absence or presence of a given activity or state, such as awareness of course aims
* verbal data, which were subjected to content analysis
to various degrees.
In analysing aspects related to the content of the courses, the classification used was derived from The Future General Practitioner (RCGP, 1972), except that the area of Human Development was incorporated into Human Behaviour. When analysing the content of some courses, it became clear that individual topics could belong more comfortably to another category in our classification; for instance, Consultation Skills or Small Group Work was reclassified as Communication, Medical Anthropology as Medicine and Society, and Epidemiology and Community Medicine were considered synonymous. An example of this would be the module on clinical reasoning on the Guy's course, which divides into two, one being more concerned with the doctor's behaviour during decision making, the other with the patient's view of health and illness, which in our classification would fall under Medicine and Society. The social sciences module has been reclassified to the Medicine and Society subcategory. In this course there were no specific sessions concerned with clinical topics. Even the two sessions on prevention were incorporated into Epidemiology and Research. Content analysis was applied to the free text (Berelson, 1971; Carney, 1972), the answers to the questions being repeatedly subjected to categorization until a satisfactory fit was obtained. Validity and reliability of the data have been checked by submitting the analysed data to the scrutiny of the course organizers for comment, and for discussion in the case of one of the courses. No statistical analysis was performed on the data as the numbers were small, and there was considerable variation of response rate from the participants. The main purpose of the study was to describe the courses, their characteristics and outcomes and not to correlate the various components. We felt that this would require a more in-depth study, which would need to correlate the structure and content of the courses to the outcomes.
the remainder held between one and six residential meetings per year (Tables 2 and 3). The courses varied not only in length but in intensity. For instance, the Scotland course, which was a one-year course, allocated 16 sessions per year, whereas the Guy's course allocated 62 sessions per year. The MSc courses required a greater commitment from the participants. Most of the courses were organized so that the participants were required to obtain day release from their practices. Table 2. Length of course, organization and types of meetings. Length Day Sessions of Modules or per course (per (years) year) Meetings evening year NW London BPMF*
2 1
Weekly Evening 2 days Day and evening Residential only Weekly Day Weekly Day Weekly Day Weekly 1/2 days
3 6
Scotland
30 22
1 16 2 60 3 1 3 36 62 2 3 2 3 30 Oxford * This course consisted of 6 modules of 2 whole days; four of the modules had one evening meeting per module. Responses from course organizers.
Exeter UCH Guy's
Table 3. Number, length and content of residential meetings. Number (per Content Days year) NW London BPMF
2
Scotland Exeter
2 6
2 No residentials 4 2-3 /2
UCH
2-3
1
Guy's
1
2
Specific content Curriculum Introduction/ content
Introduction/ projects/feedback Introduction/ preparatory work
No residentials Responses from course organizers.
Oxford
RESULTS
Seven higher professional training courses (Table 1) were studied and the questionnaires sent to course organizers and participants were analysed. The response from the seven course organizer questionnaires was 1000o. The response from the participants varied from course to course from 16% to 10Obo, averaging 55.5%. Three of the questionnaires were not considered as they were wrongly filled in, or the participants declined to complete them.
A. Structural data
(a) Organization of meetings Two of the courses were MSc courses and as a result they had slightly different characteristics from the others. All of the courses were of one to two years' duration. The majority had weekly meetings during the day. Two of the sven courses did not hold any residential meetings and
(b) Participant data Three of the seven courses were aimed specifically at young principals, that is principals with less than seven years' experience in practice (Table 4). The intended target group was reflected in the average age of the participants and their years in practice (Table 5). Tables 5-8 give particulars of the participants and their practices. It is interesting to note that there was a very high number of male participants on the Scotland course. The latter also had the highest number of participants from training practices and this may have been due to the fact that the participants were identified by the regional adviser in general practice. The average age of the participants was 37.5 years with just over 700% being male; solely urban practices comprised 65.5%. Just under half the practices were training practices and although the average number of years in practice of the course participants was 8.1 years, the two MSc courses at Exeter and Guy's biased this figure.
6 Table 4. Target group. Young
All
principals
principals
NW London BPMF Scotland Exeter UCH Guy's Oxford
+
+
+
+
+ + +
Age (average spread)
replied! sent
Male
Female
NW London BPMF Scotland Exeter UCH Guy's Oxford Totals
13/13 14/15 18/29 3/7 6/15 4/12 3/19 61/110
8 11 17 0 3 2 2
5 3 1 3 3 2 1
(%7)
(55.5)
43/61 (70.5)
17/61 (29.5)
(29-35) (32-56) (32-37) (32-50) (32-50) (36-59) (31-36) 37.5 (29-59) 32 41 34 40 40 42 34
Responses from participants.
Table 6. Practice situation. Rural
Not Mixed applicable*
NW London BPMF
13 1 1 3 9 7 4 7 Scotland 1 2 Exeter 2 4 UCH 1 3 Guy's 3 Oxford 11 40 5 5 Totals (18.0) (8.2) (65.5) (8.2) (o) * Responses from participants who were not general practitioners. This group consisted of a dentist, a community physician and other health
professionals (e.g. occupational therapist and nurse manager).
Mean number of partners (spread)
NW London BPMF Scotland Exeter UCH Guy's Oxford
2.7 (1-7) 4.4 (2-6) 4 (2-7) 4 3.75 (1-4) 4.6 (2-6) 1.7 (1-2)
Responses from participants.
years
(spread)
5030 9330 7090 6700 5750 8975 2930 6543
(1200-12000) (5000-13500) (1800-13000)
(4500-7000) (3900-11500) (1980-3500) (1200-13500)
Responses from participants. * Represents only one general
Table 5. Age and sex of participants. Number
Table 7. Number of partners, practices.
Personal
(spread) NW London BPMF Scotland Exeter* UCH Guy's Oxford Average
Responses from course organizers.
Urban
Table 8. Practice data: List sizes. Practice
in practice, and training
Years in practice (spread)
Training practice
1/13 9/14 12/18 1/1 1/6 4/4 0/3
1.8 7.6 5.16 13 8.25 17 4
(1-5) (2-30) (3.5-8) (5-14) (6-24) (3.5-5)
1300 1888 1670 2000 2100 2100 1830 1841
(800-3200) (800-3200) (1000-2300)
(1500-4500) (1900-3600) (0-3500) (0-4500)
practitioner (multiprofessional course).
B. Evaluation of curriculum planning
1. What are the needs? There appeared to be two main reasons for the origin of the courses. The first related to the learning needs of the general practitioners, and the second to the developmental needs of the department responsible for the course. Table 9 shows the reasons as described by the course organizers and the aims and objectives of the courses.
2. What are the aims and objectives? The aims of the course as perceived by the participants, the aims of the course organizers and whether or not they had been fulfilled are shown in Tables 10 and 11. The aims of the participants were divided into four areas: action goal, change, cognitive and affective. By action goal, we mean the participants' intention to achieve a specific goal, such as performing research, completing an MSc thesis or introducing changes within the practice. Thble 10 shows that the majority wanted changes in the cognitive areas (80.3%) and affective areas (73.8%). In this respect it is worth referring to Table 27, which indicates that there appeared to be a high success in these aims being fulfilled: cognitive (95.9%) and affective (100%). 3. What content should be included? Table 12 shows the content of each of the courses. A percentage figure has been calculated for the relevant amount of time that was spent on each of the four broad
categories. Three of the course organizers saw their courses as extensions to vocational training and consequently had a similar content to their course. Indeed most of the courses contained common themes; for example, NHS structure appeared in six out of the seven courses whilst management research and audit featured in four of the seven courses. The amount of time spent on the four categories varied, although two courses (Oxford and NW London) were very similar. For example, UCH devoted 62% of the time to Medicine and Society while the BPMF course devoted just over 4%. Similarly the Glasgow and Exeter courses devoted over 45% of their time to practice areas whereas the UCH course spent just over 16% on this area.
7 Table 9. Needs, aims and objectives of course organizers. Reason for course as described by Aims and objectives course organizers NW London
Need for support and To identify and further training for address educational needs; to facilitate young principals personal and professional growth; to facilitate the learning and application of performance review, and encourage continuing medical education
Table 10. Aims of the participants. Action goal (e.g. do
MSc)
Change (e.g. role, career)
1
-
2
-
3 4 1 1 2 1
10/61 (16.4)
12/61 (19.6)
research! NW London BPMF Scotland Exeter UCH Guy's
-
3 -
4
Oxford Totals
(01o)
Cognitive (know- Affective (attitude ledge, change) skills) 13 8 14 3 5 1 1 45/61 (73.8)
12 8 16 3 4 3
3 49/61 (80.3)
Responses from participants. BPMF
Experimental 1-year course replacing short courses; in consultation with Thames regional advisers; pilot for future MSc course
Scotland
Provide opportunity for general practitioners to increase their proficiency in certain areas of general practice
Need for CME course To encourage critical especially for young thinking and to make both qualitative and principals quantitative judgements on certain areas of general practice
Table 11. Aims of the course.
Knowledge of aims of course No answer
NW London BPMF Scotland Exeter UCH Guy's Oxford
Totals Need to train leaders in health professions
Extend horizons of health care professionals
UCH
Inadequate training of general practitioners for work in inner cities. Combining departments of general practice and community medicine
Preparing for change in primary care. Encourage interest in epidemiology in general practice
Guy's
Interest in continuing medical education. Wish to teach social sciences and clinical
Develop critical work in practice and undertake original work
Exeter
reasoning to general practitioners Oxford
Need for CME course To build on especially for young vocational training, each term having principals specific objectives
Responses from course organizers.
(0O)
Fulfilled
Yes
No
Yes
No
-
13
-
4
7 17 2 4 3 1
2 1
-
13 9 18 2 4 3 2
5/61 (8.2)
51/61 (83.6)
5/61 (8.2)
-
1 -
1 2 1
-
-
1
47/61
(77.0)
-
-
1
4/61 (6.5)
Responses from participants.
4. How should the content be organized? There were two main approaches to content: (a) a horizontal approach, in which each term consisted of a different module, each module being only vaguely linked; (b) a vertical approach, in which the modules were run in parallel, each term with more than one module, there being a definite connection between each term.
5. What educational strategies should be adopted? All the courses involved some form of project or audit (Thble 13), and except for two courses a high number of participants were involved in an audit or project. Table 14 shows the areas in which they carried these out. The most popular area appears to have been the practice. Curriculum planning was principally by the course organizers but in some the department or steering group assisted. The courses varied in the degree of involvement of participants in their planning from no involvement at all to one where the participants were responsible for the planning and group leadership of the sessions (1hble 15). Most of the courses relied on resources from within the course or department.
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Table 12. Content and structure of the course. Health and disease
Human behaviour
Medicine and society
Practice
(39%) NHS structure Medicine and society Epidemiology Ethics (4%) NHS structure
(28%) Management Audit
NW London
(15%) Prevention and health education Clinical topics
(17%) Communication Self-management
BPMF
(28%) Clinical advances
(39%) Communication Teamwork
Scotland
Self-management (33%) Leadership Communication Teamwork (3 7%) Leadership Education
(15%) Clinical topics
Exeter
UCH
Oxford
(6%) NHS structure (18%) NHS structure
(22%) Clinical medicine (24%) Learning Clinical reasoning
Guy's
(25%) Psychological problems Teamwork
(33%) Prevention and health education Chronic diseases
(29%) Management Research Information technology (46%) Management Audit (45%) Research Information technology Audit (16%) Management
(62%) Epidemiology NHS structure Medicine and society (43%) Ethics Medicine and society NHS structure Epidemiology (25%) Epidemiology NHS structure Medicine and society Ethics
(33%) Research
(17%) Management Audit Research
Responses from course organizers.
Table 15. Curriculum planning.
Table 13. Written work carried out.
Projects!
MSc dissertations
audits NW London BPMF
NW London
+ + + + + + +
Scotland Exeter UCH Guy's Oxford
Essays
-
BPMF +
+ +
Scotland Exeter
Table 14. Projects/audits/dissertations. Health and Human disease behaviour
(%)
13 (100) 7 (50) 14 (77.7) 2 (66.6) -
2 (50) 3 (100) 41/61
(67.2)
Responses from participants.
organizers Course organizer
Session design Course organizers Course
Participant planning Design/lead sessions None
organizer/ tutors
Responses from course organizers.
NW London BPMF Scotland Exeter UCH Guy's Oxford Totals
By whom Course
-
Medicine and society 13 (100)
Practice
-
-
1/61
16/61
13 (100) 5 (35.7) 18 (100) 3 (100) 4 (66.6) 4 (100) 2 (66.6) 49/61
(1.6)
(26.2)
(80.3)
1 (33.3) -
-
-
2 (66.6) -
1 (25)
UCH
Guy's
Course
Course
organizers
organizers Choice of
Course
organizer/ senior staff multiprofessional Course organizer/ department staff Course
organizer Oxford
Tutor/
steering group Responses from course organizers.
Identified needs
speaker/ Organize empty slots Course
organizer
Given menu/ discussed
Attend steering organizer/ group university staff Design/lead sessions Tutor Design sessions Course
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Table 16 shows the wide variation of the degree of involvement of the participants in the planning of the course: 23% of the participants were involved in the planning although the majority of these came from one course. A large number (42.6%) stated that they were not involved in any planning.
-
NW London BPMF Scotland Exeter UCH Guy's Oxford
-
Responses from course organizers.
Table 16. Participants' involvement in planning. Some
No
13
-
-
-
-
-
10 3 3 2
14 6
14/61 (23.0)
18/61 (29.5)
Yes NW London BPMF Scotland Exeter UCH Guy's Oxford
Totals
(N)
-
-
1
No answer
2
2 3 1
26/61 (42.6)
Table 17. Percentage usage of learning/teaching methods. Small Outside Large resources groups groups
1 -
3/61 (4.9)
Responses from participants.
6. What teaching methods should be used? Table 17 examines the teaching methods used by the courses, as identified by the course organizers. There appeared to be a great deal of variation between the courses on the use of outside resources and the amount of small group work.
85 25 100 50 25 50 50
15 75 0 50 75 50 50
5 90 0 50 25 25 75
7. How should assessment be carried out? Table 18 shows how the courses were evaluated (responses from course organizers). This table is divided into five columns. The first indicates why the evaluation was carried out; subsequent columns indicate by whom it was carried out, whether it was formative or summative, the methods used, and what was evaluated. Again there was a wide variation, from only a summative evaluation at the end of the course to courses which had continuous formative and summative evaluations. No external evaluation was used. Assessment of the participants was performed at the two MSc courses and contributed to the evaluation of the course as evidence of the degree of success of the course design. At least two
Table 18. Evaluation of courses.
Formative! NW London
For (why?) Course organizer
By (whom?) Participants
summative Formative + summative
RCGP faculty RCGP faculty planning BPMF
Course organizer
Participants
Summative
Scotland
Funders Planning
Formative + summative
Exeter
Participants Planning *Degree
Course organizer Participants Staff Participants Staff External examiners
UCH
Funders Future planning
Guy's
Participants
Essays Verbal Examination Thesis Formative + summative
Method Questionnaire Verbal What Sort of Doctor? Reports Questionnaire Verbal Observation Verbal Content Content Content, outcome Outcome Questionnaire
What Content, process Methods, outcome
Content, outcome Methods, process Process, outcome Content
Content, method, outcome, process,
Speakers Regional medical officer Course organizer Course organizer
Department
Formative + summative
Questionnaire
Formative Formative Formative + summative
Visit Visit Course book
practice Process, method Practice Practice
Method, process, outcome
Course organizer planning Participants
Oxford
Participants *Degree
Course organizer Staff/external
Course tutors, planning
Participants, course organizer
examiners
Formative + summativV
Questionnaire,
Content, process,
Formative + summative
verbal Verbal
outcome Outcome
Summative Formative + summative
Thesis
Outcome
Audit, visits, questionnaire,
Content, outcome, methods, process
reports
Responses from course organizers.
* Assessment of participants.
10 courses used practice visits or a "What Sort of Doctor?" exercise, and in one course participants were required to complete this exercise at the beginning and at the end of the course.
8. How should the details of the curriculum be communicated? Details of the curriculum were communicated to the participants by loose-leaf sheets. The MSc and UCH courses produced a brochure and a syllabus. The NW London course produced a 'work book' for each module which contained the tasks and the references. One course had a steering committee which met regularly for the purposes of planning and evaluation and feedback from the tutor to the committee.
9. What educational environment should be fostered? Tables 19 and 20 show the participants' positive and negative feelings about the group activities. A low number reported positive perceived change on other members of the group, while almost half reported negative dynamics in the group.
by the regional adviser or previous graduates of the course. Most of the courses were not oversubscribed. Although many of the courses received a number of enquiries, the number of firm applications rarely exceeded double the number of places available. The number completing the course ranged from 68% to 10007 (Table 22). Most of the courses had minimal selection methods, although the MSc courses tended to rely more on curriculum vitae and interviews (Table 23). Other factors contributing to the selection of the participants included considerations such as geographical convenience, distance and time necessary for travel, order of applications and potential problems caused by the absence of participants from their practices. Table 21. Methods of advertising. Family Word practitioner of committee Journals mouth NW London BPMF Scotland
+ +
Exeter UCH
+ +
Guy's Oxford
+
+ +
+
-
RCGP faculty
+ -
Table 19. Positive feelings by participants about group activities.
Support NW London BPMF
8 6 Scotland 16 2 Exeter 1 UCH 2 Guy's 3 Oxford Totals 38/61 (%) (62.3) Responses from participants.
Perceived Working change on together Learning others 9 9 10 2 1 2
9 7 6 3 3 3
+ +
+ +
+ +
+
+
+
Through regional advisers and MSD Foundation graduates Press conference -
Responses from course organizers.
1 1 2
Table 22. Applications and numbers starting and completing course.
Completed
-
33/61 (54.1)
Other
31/61 (50.8)
4/61 (6.5)
Table 20. Negative feelings by participants about group activities. Lack of cohesion Leadership Dynamics NW London 2 5 6 4 BPMF 4 9 4 Scotland 11 5 2 Exeter 3 2 3 1 UCH 2 Guy's 1 Oxford 1 Totals (N7) 16/61 (26.2) 20/61 (32.8) 29/61 (47.5) Responses from participants.
10. How should the process be managed? (a) Recruitment of participants. Table 21 shows that a variety of methods of advertising were used, although one course depended solely on participants being identified
NW London BPMF Scotland Exeter UCH
Guy's Oxford Totals (%)
Applications
Started
1-2 1 1 1 1 1-2 1-2
16 16 33 9 22 12 24 132
x x x x x x x
(%Mo) 13 15 29 7 15 12 19 110
(81) (93) (87) (77) (68) (100) (79) (83.3)
Responses from course organizers.
(b) Finances. Table 24 shows the finances involved in running the courses. Most courses would have enjoyed the help of a specific full-time secretary but were required to rely on secretarial assistance from within existing resources. The finance of the courses varied from £1590 per participant per year to £180 per participant per year exclusive of the hotel costs of the residentials. Similarly there was a wide variance in cost per participant per session from £45 to only £6. It would appear that the most costly courses were the MSc courses, although it needs to be pointed out that these courses attracted some degree of direct reimbursement to the participants from the regional advisers.
11 Table 23. Selection methods.
Visits by course organizer
Interviews NW London BPMF Scotland Exeter UCH Guy's Oxford
+ + +
-
Recornmended
CV and references
Years in practice
+
5y >3y
Higher Professional Education Courses in the United Kingdom SUMMARY The need for higher professional education courses has been well established by young principals, medical educationalists and the Royal College of General Practitioners (RCGPR 1985a, 1987 and 1990; Regional Advisers, 1989). In recent years there has been an increase in their development. However there is still a small number catering for a very small group ofpotential learners. These courses have often been seen as an extension of vocational training. Seven such courses were identified and evaluated during this project. The method and the results of the evaluation are presented. The development of higher professional education courses needs to be tailored to particular local needs and any central planning can be stifling. In our project there was often inadequate organizational and financial support available. The courses proved to be demanding for the participants in terms of time and required motivation. Despite this, attendance was good. Much of the content of the courses laid emphasis on practice management, human behaviour, and medicine and society, which reflected the perceived needs of both organizers and participants. Where formative evaluation of the courses was carried out, this appeared to have an important effect on course development. However fewer than 50% of the participants were involved to any extent in any planning of the courses, which is clearly contrary to the recognized principles of adult or self-directed learning (Brookfield, 1986). Despite this, participants as a whole appreciated the courses and the effect these had on their work, a large proportion reporting a significant change in cognitive and affective areas of learning. Recommendations are made for future organizers of higher professional education courses.
INTRODUCTION "If the licence to practice meant the completion of his education, how sad it would be for the practitioner, how distressing to his patients! More clearly than any other, the physician should illustrate the truth of Plato's saying that education is a life-long process" (Osler, 1900).
DESPITE Osler's pronouncement ninety years ago, continuing medical education (CME) programmes are a relatively recent phenomenon in British general practice. They emerged following the Nuffield Provincial Hospitals Trust Conference held in 1961 (NPHT, 1962) and since that time continuing medical education has progressed rapidly. With the emergence of the Government's white paper on the National Health Service (Secretaries of State, 1989) and the new contract (Health Departments, 1989) the indications are that it is likely to change even more dramatically in the next few years not only in the design of programmes but also in the needs of general practitioners and their commitment to it. The history of vocational training for general practice has been well documented (Horder and Swift, 1979; Hasler, 1989). The need for special postgraduate training for general practice may have been recognized as long ago as 1884 (National Association of General Practitioners in Medicine, Surgery and Midwifery, 1845). Vocational training was introduced almost thirty years ago and became mandatory for NHS practice in 1981. However, despite this many trainees still find themselves ill prepared for their new practices whose standards and priorities may differ from their training practices. Although vocational training is for three years, the original recommendation from the College of General Practitioners (1966) and the Royal Commission on Medical Education (Todd Report, 1968) was for a fiveyear period of training for general practice, two years of
which was to be in general practice and three years in hospital posts. In some European countries a voluntary five-year programme for training exists (Horder, 1988). It is therefore perhaps not surprising that demands have been made for a further period of professional training for young principals (RCGP, 1985a, 1987). The aims and objectives of vocational training have been stated (RCGP, 1972; Second European Conference, 1974; RCGP, 1978; Oxford Region, 1986). As technology and knowledge have increased over the past two decades, the problems of coping with a "hypertrophied curriculum" (Abrahamson, 1978) in a limited training period have mounted. Despite attempts to ensure that the training is comprehensive, it is rarely possible for the trainee to be fully prepared for every situation that he or she will encounter in practice. Experience in the management of terminal care, for instance, may not be universal in the trainee year, and it has been shown that a trainee will see 75% of asthmatics and diabetics less than twice (Hasler, 1983; Adam and Oswald, 1985). Other aspects such as epidemiology, ethics, research, performance review, teamwork and practice management may not appear relevant or sufficiently important at the time. In a study asking trainers to rank the aims of general practice training, these same areas achieved lowest scores of importance (Tate and Pendleton, 1980). Continuing education should reflect changes in the way general practitioners practise and therefore it needs to be continuous. It is to be hoped that the trainee year will have been successful in encouraging and motivating the trainee to assume responsibility for his continuing education. But where can the young principal turn to for his continuing education? The Nuffield conference of 1961 under the chairmanship of the late Sir George Pickering made recommendations which led to the development of the modern
2
postgraduate centre movement (NPHT, 1962). The formal programmes laid on by these centres for general practitioners were organized by hospital clinicians who had themselves decided on the content and format of the meetings, often without consulting the needs of the learners. The emergence of the general practitioner tutor (Berrington and Varnam, 1987) in many postgraduate centres has enabled the programmes to be more relevant to general practitioner needs. Despite this, attendance at lunchtime meetings is still depressingly low and has fallen since they ceased to become obligatory for seniority payments (Pickup et al., 1983a) and expenditure was cash-limited. This is bound to change with the impact of the new contract (Health Departments, 1989), which demands that all general practitioners attend 10 educational sessions per year to qualify for the postgraduate education allowance (PGEA). Self study has been a popular method amongst general practitioners as a method of continuing medical education (Scottish Council for Postgraduate Medical Education, 1979). Pickup et al. (1983a) found that general practitioners spent on average 140 hours per year on reading journals and periodicals. The University of Dundee has been instrumental in developing distance learning programmes for general practitioners and these have increased in popularity in recent years. Educational activities within the practice (Reiss et al., 1981; Owen et al., 1989), the presence of a trainee in the practice or the process of becoming a trainer have also been regarded as a valuable learning experience. However, general practitioner principals are usually unable to become trainers for at least three or sometimes five years. Young practitioner groups have gone some way to easing the situation but they can be too cosy for learning to take place and may lack effective leadership. However, their spontaneous formation throughout the country suggests a genuine need as perceived by the young general practitioner (Rhodes, 1983; Stott, 1984; Edwards et al., 1988). Support for higher professional training courses as a way of promoting the further development of the young principal has come from various sources. The Royal College of General Practitioners has supported their development (RCGP, 1985a, 1987 and 1990). Similarly the 1989 Conference of Local Medical Committees and the 1989 working party of the Regional and Associate Regional Advisers in General Practice (1989) have requested additional funding for their development. In several parts of the country higher professional education courses have begun to emerge (Courtenay et al., 1982; Parry and MacFarlane, 1983; MacInnes, 1987). Organized continuing education has traditionally been by Section 63 meetings in postgraduate centres, which have tended to be poorly attended. Research has indicated that this does not appear to be due to the content or methodology (Pickup et al., 1983b). Until fairly recently, medical education has been influenced by the traditional approach to learning, based on behavioural objectives. This demands that the course teacher should define observable behavioural objectives (cognitive, psychomotor or affective) and develop teaching methods to implement the desired learning, and assess the achievements in relation to the stated objectives. The main criticisms of this approach have been:
(a) practical: that to define and measure objectives in a number of areas which are especially relevant in general practice, for example attitudinal changes, is difficult. Furthermore to produce objectives for the whole course is time consuming, does not allow for discovery learning, and tends to produce trivial objectives. (b) theoretical: that a list of actions does not represent a structure of knowledge, as there are a number of different paths through any body of knowledge. Consequently any assessment may not be valid and the use of objectives does not cover all the interactions between student and teacher (Beard and Hartley, 1986). Recommendations have been made by researchers that more attention be paid to the theories of adult education. It has been suggested that courses need to be based upon a sound curriculum plan which follows a sequence of logical steps (Bandarnayake, 1985). In particular CME activities should be more self-directed and self-determined (Wood and Byrne, 1980; Stone et al., 1982; Bandarnayake, 1985; Horder et al., 1986; Branthwaite et al., 1988). A great deal of work has been carried out in recent years on adult education and the adult learner. The relatively new concept of andragogy has gained increasing acceptance amongst educators. Andragogy has four basic assumptions (Knowles, 1980): 1. That adults both desire and enact a tendency toward self-directedness 2. That adult experiences are a rich resource of learning 3. That adults are aware of specific learning needs generated by real life tasks or problems 4. That adults are competency-based learners in that they wish to apply newly acquired skills or knowledge; i.e. they are performance centred in their orientation to learning. Andragogy represents a model of learning consisting of a set of assumptions about the way adults learn. It can be contrasted with pedagogy, which implies a greater gradient of power and knowledge between educator and learner. The concept of andragogy helps adult educators to define their approach as being more collaborative and facilitative. At the centre of this theory is the concept of the self-directed learner. A self-directed learner is one who "with or without the help of others, identifies his or her learning needs, sets relevant feasible and measurable learning objectives; determines generally accepted standards or criteria which will be applied to assess whether learning has in fact occurred as planned; and finally formulates a coherent learning agreement or personal curriculum for the course" (Knowles, 1975). The benefits of self-directed learning are clearly that the needs of the individual are identified and will be matched to the objectives of the course. Self-directed learning encourages the pursuit of continuing education through the encouragement of autonomous learning (Hammond and Collins, 1987). Critics of Knowles' concepts have disputed his definition of adulthood and the development of selfdirectedness based on the attainment of a certain chronological age (Brookfield, 1986). Others have stressed the importance of viewing the adult and his propensity to self-directedness as a product of his society and
3
culture (Fromm, 1942; Nottingham Andragogy Group, 1983). The courses should reflect the principles of andragogy and the following guidelines have been suggested (Brookfield, 1986): 1. Participation is voluntary and therefore must appeal to potential participants. 2. Respect among the participants for each other's worth needs to be established. The group facilitator needs to have adequate group leadership skills. 3. Facilitation is collaborative. Autonomy needs to be encouraged. Participants should be invited to participate in the design and implementation of the courses. 4. Kolb and Fry (1975) saw learning as a circular process of four stages in which Concrete Experience is followed by Reflection and Observation which leads to the formulation of Abstract Concepts and Generalizations which may be tested in Active Experimentation. This process needs to be continuous throughout the course. 5. Critical reflection should be encouraged. Increased awareness and the questioning of values, standards and morals will facilitate the process of personal and professional growth. 6. The aim should be to encourage the nurturing of the self-directed pro-active adult.
BACKGROUND TO STUDY The need for higher professional education courses has already been established (RCGP, 1985a, 1987 and 1990; Regional Advisers, 1989). The stimulus for this study arose from: 1. The lack of knowledge of the provision of such courses, their content and organization 2. The need to provide an evaluation of these courses and appraise their educational value 3. The need to discover whether CME activities follow the principles of adult education 4. The lack of a directive lead from any educational and political body in recognizing the specific learning needs of young principals and the need for protected
time. The aims of the study, which arose from these needs, were to examine higher professional education courses throughout the country and specifically: 1. 'l provide a descriptive documentary. We were interested in exploring their content, their design, their curricula and their methods of evaluation and assessment 2. lb find out to what extent they addressed the needs
of the participants and the institutions 3. 'b evaluate the courses against certain criteria, namely whether there was a need for such courses and to what extent principles of adult learning were adhered to
4. To examine the management of the courses. It seemed to us that a study of this nature had not been undertaken before and the information obtained might help future organizers in the setting up of such courses.
METHODS OF THE STUDY 1. Identification of courses For the purposes of this study we were prepared to look at any course which was aimed specifically at young principals and which was of at least one year's duration. A young principal was defined as a general practitioner with less than seven years' experience of general practice. A letter was sent to all the regional advisers in general practice, RCGP faculty secretaries, and heads of departments of general practice requesting any information on such courses. As a result of this enquiry seven courses were identified which fulfilled our criteria (Table 1). A brief synopsis of their content is given in Appendix 1. Table 1. Organizers and titles of courses.
Organizer North and West London Faculty of the Royal College of General Practitioners (NW London) British Postgraduate Medical Federation, University of London (BPMF) MSD Foundation (Scotland) Department of General Practice, Postgraduate Medical School, University of Exeter (Exeter) Department of General Practice and Community Medicine, University College Hospital (UCH) Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's Hospitals (Guy's) Oxford Regional Committee for Postgraduate Medical Education and Training; University Department of Public Health and Primary Care; Thames Valley Faculty, Royal College of General Practitioners (Oxford)
Title Higher Professional Education Course Advanced General Practice GP Now MSc in Health Care
Health for 2000: Changing Primary Care MSc in General Practice
Higher Professional Training Courses for General Practice
2. Data collection We decided to study all the courses and obtain data from all the course organizers and participants. Two groups of data were collected: descriptive (i.e. factual) and evaluative (i.e. qualitative), expressing mainly opinions and
perceptions. Three principal sources of data collection were used: questionnaires, interviews and documentary sources.
4
Questionnaires Postal questionnaires were to be the principal method of data collection. The questionnaires were by design predominantly open ended. Such open-ended questions are considered to be indispensible for exploratory studies (Morris, 1987; Woodward, 1988). These elicited answers that were not constrained by previously determined criteria. This can be seen in question 9 in the questionnaire to the participants where the impact of the course on the practice and the participant was looked for (page 22). This 'goal free evaluation' (Scriven, 1972) allows the respondent to focus on what is perceived by him to be important, and often a personal dimension may emerge which may not have been anticipated by the survey designer or elicited by a more closed form of questionnaire. This applies especially to the affective aspects of development of 'personal growth', which is difficult to plan for yet is acknowledged by educationalists to be of fundamental importance. Analysis of open-ended questionnaires can, however, present problems. Despite this, only the responses to question 8 were discounted as these proved too difficult to interpret. Course organizers: The questionnaire which was sent to all the course organizers (Appendix 2) was designed to elicit descriptive data (a) about the course, such as frequency and duration of meetings, means of advertising and selection; (b) about the course organizers, such as number, support and training; (c) about curriculum planning, such as the design of the courses and sessions; (d) use of outside resources; and (e) aspects of adult learning such as participant involvement. Participants: Each participant was sent a questionnaire (Appendix 3) and non-responders were followed up with two reminders. The questionnaire was developed to elicit two types of data: (a) structural/descriptive relating mainly to participants and their practices; and (b) evaluative relating to their experience of the course and the perceived impact on their work and professional life. Aspects of adult learning were explored through questions on participation in planning the course and congruence between the course design and aims of participants, and the fulfilment of these aims. Interviews Course organizers: Semistructured interview schedules were constructed after receipt and preliminary analysis of the questionnaires to clarify some data such as reasons courses were started, content of certain sessions, and additional data such as costs of the courses, numbers completing them, attendances, problems experienced by course organizers in management of the courses, and methods of evaluation. All the course organizers were interviewed face to face, and these interviews extended over one hour. Interviews were hand and/or tape recorded and transcribed in three cases to verify the completeness and reliability of the manual recording. One of us (RGP) was invited to attend the meeting of the steering committee of the course This meeting extended over a two-hour period and provided useful information on the management problems associated with the course. Participants: The questionnaire was piloted during its development by using the questions as a basis for interviews with randomly selected participants to establish the
feasibility and validity of the questions. In two cases the interviews were tape recorded to check the reliability of the answers. Documentary evidence Documentary evidence concerning the courses such as advertisements, timetables, workbooks, and reading lists were obtained. These provided the necessary descriptive data about factors such as the content and structure of the courses and number of sessions. 3. Data presentation The data have been presented in the following sections: A. Structural data Information is provided about the course and the participants and their practices.
B. Evaluation of curriculum planning This has been presented after Harden (1986), who presented an educational model of progress from needs to management through 10 questions:
What are the needs? What are the aims and objectives? What content should be included? How should the content be organized? What educational strategies should be adopted? What teaching methods should be used? How should assessment be carried out? How should details of the curriculum be communicated? 9. What educational environment should be fostered? 10. How should the process be managed? 1. 2. 3. 4. 5. 6. 7. 8.
C. Outcomes Each of these three sections contains responses from both the participants and the course organizers. 4. Data analysis The data obtained from the respondents fall into two main groups:
Numerical Numerical data are presented in a raw format, such as number of partners, or have been derived from the answers, for example the cost of the course/participant/ year.
Verbal Verbal data are presented in three formats: * as free text, such as the title of the course to illustrate the range of answers, or to illustrate viewpoints where categorizations would have been difficult and not helpful * numerically, in the case of easily quantifiable verbal responses indicating simple absence or presence of a given activity or state, such as awareness of course aims
* verbal data, which were subjected to content analysis
to various degrees.
In analysing aspects related to the content of the courses, the classification used was derived from The Future General Practitioner (RCGP, 1972), except that the area of Human Development was incorporated into Human Behaviour. When analysing the content of some courses, it became clear that individual topics could belong more comfortably to another category in our classification; for instance, Consultation Skills or Small Group Work was reclassified as Communication, Medical Anthropology as Medicine and Society, and Epidemiology and Community Medicine were considered synonymous. An example of this would be the module on clinical reasoning on the Guy's course, which divides into two, one being more concerned with the doctor's behaviour during decision making, the other with the patient's view of health and illness, which in our classification would fall under Medicine and Society. The social sciences module has been reclassified to the Medicine and Society subcategory. In this course there were no specific sessions concerned with clinical topics. Even the two sessions on prevention were incorporated into Epidemiology and Research. Content analysis was applied to the free text (Berelson, 1971; Carney, 1972), the answers to the questions being repeatedly subjected to categorization until a satisfactory fit was obtained. Validity and reliability of the data have been checked by submitting the analysed data to the scrutiny of the course organizers for comment, and for discussion in the case of one of the courses. No statistical analysis was performed on the data as the numbers were small, and there was considerable variation of response rate from the participants. The main purpose of the study was to describe the courses, their characteristics and outcomes and not to correlate the various components. We felt that this would require a more in-depth study, which would need to correlate the structure and content of the courses to the outcomes.
the remainder held between one and six residential meetings per year (Tables 2 and 3). The courses varied not only in length but in intensity. For instance, the Scotland course, which was a one-year course, allocated 16 sessions per year, whereas the Guy's course allocated 62 sessions per year. The MSc courses required a greater commitment from the participants. Most of the courses were organized so that the participants were required to obtain day release from their practices. Table 2. Length of course, organization and types of meetings. Length Day Sessions of Modules or per course (per (years) year) Meetings evening year NW London BPMF*
2 1
Weekly Evening 2 days Day and evening Residential only Weekly Day Weekly Day Weekly Day Weekly 1/2 days
3 6
Scotland
30 22
1 16 2 60 3 1 3 36 62 2 3 2 3 30 Oxford * This course consisted of 6 modules of 2 whole days; four of the modules had one evening meeting per module. Responses from course organizers.
Exeter UCH Guy's
Table 3. Number, length and content of residential meetings. Number (per Content Days year) NW London BPMF
2
Scotland Exeter
2 6
2 No residentials 4 2-3 /2
UCH
2-3
1
Guy's
1
2
Specific content Curriculum Introduction/ content
Introduction/ projects/feedback Introduction/ preparatory work
No residentials Responses from course organizers.
Oxford
RESULTS
Seven higher professional training courses (Table 1) were studied and the questionnaires sent to course organizers and participants were analysed. The response from the seven course organizer questionnaires was 1000o. The response from the participants varied from course to course from 16% to 10Obo, averaging 55.5%. Three of the questionnaires were not considered as they were wrongly filled in, or the participants declined to complete them.
A. Structural data
(a) Organization of meetings Two of the courses were MSc courses and as a result they had slightly different characteristics from the others. All of the courses were of one to two years' duration. The majority had weekly meetings during the day. Two of the sven courses did not hold any residential meetings and
(b) Participant data Three of the seven courses were aimed specifically at young principals, that is principals with less than seven years' experience in practice (Table 4). The intended target group was reflected in the average age of the participants and their years in practice (Table 5). Tables 5-8 give particulars of the participants and their practices. It is interesting to note that there was a very high number of male participants on the Scotland course. The latter also had the highest number of participants from training practices and this may have been due to the fact that the participants were identified by the regional adviser in general practice. The average age of the participants was 37.5 years with just over 700% being male; solely urban practices comprised 65.5%. Just under half the practices were training practices and although the average number of years in practice of the course participants was 8.1 years, the two MSc courses at Exeter and Guy's biased this figure.
6 Table 4. Target group. Young
All
principals
principals
NW London BPMF Scotland Exeter UCH Guy's Oxford
+
+
+
+
+ + +
Age (average spread)
replied! sent
Male
Female
NW London BPMF Scotland Exeter UCH Guy's Oxford Totals
13/13 14/15 18/29 3/7 6/15 4/12 3/19 61/110
8 11 17 0 3 2 2
5 3 1 3 3 2 1
(%7)
(55.5)
43/61 (70.5)
17/61 (29.5)
(29-35) (32-56) (32-37) (32-50) (32-50) (36-59) (31-36) 37.5 (29-59) 32 41 34 40 40 42 34
Responses from participants.
Table 6. Practice situation. Rural
Not Mixed applicable*
NW London BPMF
13 1 1 3 9 7 4 7 Scotland 1 2 Exeter 2 4 UCH 1 3 Guy's 3 Oxford 11 40 5 5 Totals (18.0) (8.2) (65.5) (8.2) (o) * Responses from participants who were not general practitioners. This group consisted of a dentist, a community physician and other health
professionals (e.g. occupational therapist and nurse manager).
Mean number of partners (spread)
NW London BPMF Scotland Exeter UCH Guy's Oxford
2.7 (1-7) 4.4 (2-6) 4 (2-7) 4 3.75 (1-4) 4.6 (2-6) 1.7 (1-2)
Responses from participants.
years
(spread)
5030 9330 7090 6700 5750 8975 2930 6543
(1200-12000) (5000-13500) (1800-13000)
(4500-7000) (3900-11500) (1980-3500) (1200-13500)
Responses from participants. * Represents only one general
Table 5. Age and sex of participants. Number
Table 7. Number of partners, practices.
Personal
(spread) NW London BPMF Scotland Exeter* UCH Guy's Oxford Average
Responses from course organizers.
Urban
Table 8. Practice data: List sizes. Practice
in practice, and training
Years in practice (spread)
Training practice
1/13 9/14 12/18 1/1 1/6 4/4 0/3
1.8 7.6 5.16 13 8.25 17 4
(1-5) (2-30) (3.5-8) (5-14) (6-24) (3.5-5)
1300 1888 1670 2000 2100 2100 1830 1841
(800-3200) (800-3200) (1000-2300)
(1500-4500) (1900-3600) (0-3500) (0-4500)
practitioner (multiprofessional course).
B. Evaluation of curriculum planning
1. What are the needs? There appeared to be two main reasons for the origin of the courses. The first related to the learning needs of the general practitioners, and the second to the developmental needs of the department responsible for the course. Table 9 shows the reasons as described by the course organizers and the aims and objectives of the courses.
2. What are the aims and objectives? The aims of the course as perceived by the participants, the aims of the course organizers and whether or not they had been fulfilled are shown in Tables 10 and 11. The aims of the participants were divided into four areas: action goal, change, cognitive and affective. By action goal, we mean the participants' intention to achieve a specific goal, such as performing research, completing an MSc thesis or introducing changes within the practice. Thble 10 shows that the majority wanted changes in the cognitive areas (80.3%) and affective areas (73.8%). In this respect it is worth referring to Table 27, which indicates that there appeared to be a high success in these aims being fulfilled: cognitive (95.9%) and affective (100%). 3. What content should be included? Table 12 shows the content of each of the courses. A percentage figure has been calculated for the relevant amount of time that was spent on each of the four broad
categories. Three of the course organizers saw their courses as extensions to vocational training and consequently had a similar content to their course. Indeed most of the courses contained common themes; for example, NHS structure appeared in six out of the seven courses whilst management research and audit featured in four of the seven courses. The amount of time spent on the four categories varied, although two courses (Oxford and NW London) were very similar. For example, UCH devoted 62% of the time to Medicine and Society while the BPMF course devoted just over 4%. Similarly the Glasgow and Exeter courses devoted over 45% of their time to practice areas whereas the UCH course spent just over 16% on this area.
7 Table 9. Needs, aims and objectives of course organizers. Reason for course as described by Aims and objectives course organizers NW London
Need for support and To identify and further training for address educational needs; to facilitate young principals personal and professional growth; to facilitate the learning and application of performance review, and encourage continuing medical education
Table 10. Aims of the participants. Action goal (e.g. do
MSc)
Change (e.g. role, career)
1
-
2
-
3 4 1 1 2 1
10/61 (16.4)
12/61 (19.6)
research! NW London BPMF Scotland Exeter UCH Guy's
-
3 -
4
Oxford Totals
(01o)
Cognitive (know- Affective (attitude ledge, change) skills) 13 8 14 3 5 1 1 45/61 (73.8)
12 8 16 3 4 3
3 49/61 (80.3)
Responses from participants. BPMF
Experimental 1-year course replacing short courses; in consultation with Thames regional advisers; pilot for future MSc course
Scotland
Provide opportunity for general practitioners to increase their proficiency in certain areas of general practice
Need for CME course To encourage critical especially for young thinking and to make both qualitative and principals quantitative judgements on certain areas of general practice
Table 11. Aims of the course.
Knowledge of aims of course No answer
NW London BPMF Scotland Exeter UCH Guy's Oxford
Totals Need to train leaders in health professions
Extend horizons of health care professionals
UCH
Inadequate training of general practitioners for work in inner cities. Combining departments of general practice and community medicine
Preparing for change in primary care. Encourage interest in epidemiology in general practice
Guy's
Interest in continuing medical education. Wish to teach social sciences and clinical
Develop critical work in practice and undertake original work
Exeter
reasoning to general practitioners Oxford
Need for CME course To build on especially for young vocational training, each term having principals specific objectives
Responses from course organizers.
(0O)
Fulfilled
Yes
No
Yes
No
-
13
-
4
7 17 2 4 3 1
2 1
-
13 9 18 2 4 3 2
5/61 (8.2)
51/61 (83.6)
5/61 (8.2)
-
1 -
1 2 1
-
-
1
47/61
(77.0)
-
-
1
4/61 (6.5)
Responses from participants.
4. How should the content be organized? There were two main approaches to content: (a) a horizontal approach, in which each term consisted of a different module, each module being only vaguely linked; (b) a vertical approach, in which the modules were run in parallel, each term with more than one module, there being a definite connection between each term.
5. What educational strategies should be adopted? All the courses involved some form of project or audit (Thble 13), and except for two courses a high number of participants were involved in an audit or project. Table 14 shows the areas in which they carried these out. The most popular area appears to have been the practice. Curriculum planning was principally by the course organizers but in some the department or steering group assisted. The courses varied in the degree of involvement of participants in their planning from no involvement at all to one where the participants were responsible for the planning and group leadership of the sessions (1hble 15). Most of the courses relied on resources from within the course or department.
8
Table 12. Content and structure of the course. Health and disease
Human behaviour
Medicine and society
Practice
(39%) NHS structure Medicine and society Epidemiology Ethics (4%) NHS structure
(28%) Management Audit
NW London
(15%) Prevention and health education Clinical topics
(17%) Communication Self-management
BPMF
(28%) Clinical advances
(39%) Communication Teamwork
Scotland
Self-management (33%) Leadership Communication Teamwork (3 7%) Leadership Education
(15%) Clinical topics
Exeter
UCH
Oxford
(6%) NHS structure (18%) NHS structure
(22%) Clinical medicine (24%) Learning Clinical reasoning
Guy's
(25%) Psychological problems Teamwork
(33%) Prevention and health education Chronic diseases
(29%) Management Research Information technology (46%) Management Audit (45%) Research Information technology Audit (16%) Management
(62%) Epidemiology NHS structure Medicine and society (43%) Ethics Medicine and society NHS structure Epidemiology (25%) Epidemiology NHS structure Medicine and society Ethics
(33%) Research
(17%) Management Audit Research
Responses from course organizers.
Table 15. Curriculum planning.
Table 13. Written work carried out.
Projects!
MSc dissertations
audits NW London BPMF
NW London
+ + + + + + +
Scotland Exeter UCH Guy's Oxford
Essays
-
BPMF +
+ +
Scotland Exeter
Table 14. Projects/audits/dissertations. Health and Human disease behaviour
(%)
13 (100) 7 (50) 14 (77.7) 2 (66.6) -
2 (50) 3 (100) 41/61
(67.2)
Responses from participants.
organizers Course organizer
Session design Course organizers Course
Participant planning Design/lead sessions None
organizer/ tutors
Responses from course organizers.
NW London BPMF Scotland Exeter UCH Guy's Oxford Totals
By whom Course
-
Medicine and society 13 (100)
Practice
-
-
1/61
16/61
13 (100) 5 (35.7) 18 (100) 3 (100) 4 (66.6) 4 (100) 2 (66.6) 49/61
(1.6)
(26.2)
(80.3)
1 (33.3) -
-
-
2 (66.6) -
1 (25)
UCH
Guy's
Course
Course
organizers
organizers Choice of
Course
organizer/ senior staff multiprofessional Course organizer/ department staff Course
organizer Oxford
Tutor/
steering group Responses from course organizers.
Identified needs
speaker/ Organize empty slots Course
organizer
Given menu/ discussed
Attend steering organizer/ group university staff Design/lead sessions Tutor Design sessions Course
9
Table 16 shows the wide variation of the degree of involvement of the participants in the planning of the course: 23% of the participants were involved in the planning although the majority of these came from one course. A large number (42.6%) stated that they were not involved in any planning.
-
NW London BPMF Scotland Exeter UCH Guy's Oxford
-
Responses from course organizers.
Table 16. Participants' involvement in planning. Some
No
13
-
-
-
-
-
10 3 3 2
14 6
14/61 (23.0)
18/61 (29.5)
Yes NW London BPMF Scotland Exeter UCH Guy's Oxford
Totals
(N)
-
-
1
No answer
2
2 3 1
26/61 (42.6)
Table 17. Percentage usage of learning/teaching methods. Small Outside Large resources groups groups
1 -
3/61 (4.9)
Responses from participants.
6. What teaching methods should be used? Table 17 examines the teaching methods used by the courses, as identified by the course organizers. There appeared to be a great deal of variation between the courses on the use of outside resources and the amount of small group work.
85 25 100 50 25 50 50
15 75 0 50 75 50 50
5 90 0 50 25 25 75
7. How should assessment be carried out? Table 18 shows how the courses were evaluated (responses from course organizers). This table is divided into five columns. The first indicates why the evaluation was carried out; subsequent columns indicate by whom it was carried out, whether it was formative or summative, the methods used, and what was evaluated. Again there was a wide variation, from only a summative evaluation at the end of the course to courses which had continuous formative and summative evaluations. No external evaluation was used. Assessment of the participants was performed at the two MSc courses and contributed to the evaluation of the course as evidence of the degree of success of the course design. At least two
Table 18. Evaluation of courses.
Formative! NW London
For (why?) Course organizer
By (whom?) Participants
summative Formative + summative
RCGP faculty RCGP faculty planning BPMF
Course organizer
Participants
Summative
Scotland
Funders Planning
Formative + summative
Exeter
Participants Planning *Degree
Course organizer Participants Staff Participants Staff External examiners
UCH
Funders Future planning
Guy's
Participants
Essays Verbal Examination Thesis Formative + summative
Method Questionnaire Verbal What Sort of Doctor? Reports Questionnaire Verbal Observation Verbal Content Content Content, outcome Outcome Questionnaire
What Content, process Methods, outcome
Content, outcome Methods, process Process, outcome Content
Content, method, outcome, process,
Speakers Regional medical officer Course organizer Course organizer
Department
Formative + summative
Questionnaire
Formative Formative Formative + summative
Visit Visit Course book
practice Process, method Practice Practice
Method, process, outcome
Course organizer planning Participants
Oxford
Participants *Degree
Course organizer Staff/external
Course tutors, planning
Participants, course organizer
examiners
Formative + summativV
Questionnaire,
Content, process,
Formative + summative
verbal Verbal
outcome Outcome
Summative Formative + summative
Thesis
Outcome
Audit, visits, questionnaire,
Content, outcome, methods, process
reports
Responses from course organizers.
* Assessment of participants.
10 courses used practice visits or a "What Sort of Doctor?" exercise, and in one course participants were required to complete this exercise at the beginning and at the end of the course.
8. How should the details of the curriculum be communicated? Details of the curriculum were communicated to the participants by loose-leaf sheets. The MSc and UCH courses produced a brochure and a syllabus. The NW London course produced a 'work book' for each module which contained the tasks and the references. One course had a steering committee which met regularly for the purposes of planning and evaluation and feedback from the tutor to the committee.
9. What educational environment should be fostered? Tables 19 and 20 show the participants' positive and negative feelings about the group activities. A low number reported positive perceived change on other members of the group, while almost half reported negative dynamics in the group.
by the regional adviser or previous graduates of the course. Most of the courses were not oversubscribed. Although many of the courses received a number of enquiries, the number of firm applications rarely exceeded double the number of places available. The number completing the course ranged from 68% to 10007 (Table 22). Most of the courses had minimal selection methods, although the MSc courses tended to rely more on curriculum vitae and interviews (Table 23). Other factors contributing to the selection of the participants included considerations such as geographical convenience, distance and time necessary for travel, order of applications and potential problems caused by the absence of participants from their practices. Table 21. Methods of advertising. Family Word practitioner of committee Journals mouth NW London BPMF Scotland
+ +
Exeter UCH
+ +
Guy's Oxford
+
+ +
+
-
RCGP faculty
+ -
Table 19. Positive feelings by participants about group activities.
Support NW London BPMF
8 6 Scotland 16 2 Exeter 1 UCH 2 Guy's 3 Oxford Totals 38/61 (%) (62.3) Responses from participants.
Perceived Working change on together Learning others 9 9 10 2 1 2
9 7 6 3 3 3
+ +
+ +
+ +
+
+
+
Through regional advisers and MSD Foundation graduates Press conference -
Responses from course organizers.
1 1 2
Table 22. Applications and numbers starting and completing course.
Completed
-
33/61 (54.1)
Other
31/61 (50.8)
4/61 (6.5)
Table 20. Negative feelings by participants about group activities. Lack of cohesion Leadership Dynamics NW London 2 5 6 4 BPMF 4 9 4 Scotland 11 5 2 Exeter 3 2 3 1 UCH 2 Guy's 1 Oxford 1 Totals (N7) 16/61 (26.2) 20/61 (32.8) 29/61 (47.5) Responses from participants.
10. How should the process be managed? (a) Recruitment of participants. Table 21 shows that a variety of methods of advertising were used, although one course depended solely on participants being identified
NW London BPMF Scotland Exeter UCH
Guy's Oxford Totals (%)
Applications
Started
1-2 1 1 1 1 1-2 1-2
16 16 33 9 22 12 24 132
x x x x x x x
(%Mo) 13 15 29 7 15 12 19 110
(81) (93) (87) (77) (68) (100) (79) (83.3)
Responses from course organizers.
(b) Finances. Table 24 shows the finances involved in running the courses. Most courses would have enjoyed the help of a specific full-time secretary but were required to rely on secretarial assistance from within existing resources. The finance of the courses varied from £1590 per participant per year to £180 per participant per year exclusive of the hotel costs of the residentials. Similarly there was a wide variance in cost per participant per session from £45 to only £6. It would appear that the most costly courses were the MSc courses, although it needs to be pointed out that these courses attracted some degree of direct reimbursement to the participants from the regional advisers.
11 Table 23. Selection methods.
Visits by course organizer
Interviews NW London BPMF Scotland Exeter UCH Guy's Oxford
+ + +
-
Recornmended
CV and references
Years in practice
+
5y >3y
