Quantitative
Participants and process information
33 students took part, from first year preclinical to fifth year clinical and graduate entry students. The mode (36%) were in their fourth year (1st year of clinical studies).
The majority reported low-medium levels of previous patient interaction, whilst 2 reported almost none and 5 high levels. Around 10% had previous experience making ‘cold’ calls.
156 high risk and 1217 vulnerable patients were included, with average ages of 64 and 85 respectively. 97 ‘high risk’ and 781 ‘vulnerable’ calls were made successfully with Figure 1 detailing failed attempts. The majority were exclusions for care home residents or unanswered calls.
Medication delivery and digital connectivity
The majority of both high risk and vulnerable respondents could organise medication collection – 88% and 89% respectively. The remainder either had no capacity to do so or relied on community support groups.
Students found it challenging to collect data regarding digital connectivity. Whilst every patient had a landline, 22% of high risk and 44% of vulnerable respondents reported some impairment of connectivity i.e. either not making regular use of mobile phone, internet (and email) services, or both.
End-of-life care
Optional prompting around end-of-life care was introduced to the project after the conclusion of the high-risk calls. Data is therefore only available for 145 vulnerable patients.
Of those, 28% of respondents either had an existing care plan with a resuscitation decision or were open to further exploration. 19% expressed a desire for further discussions with a GP. In contrast, 20% reported strong views against resuscitation decisions, and a third of conversations were inconclusive. 6% of the 76 EMIS-coded resuscitation discussions that took place over the subsequent 9 weeks were for patients following student discussions.
Other medical issues
Just over 10% of vulnerable respondents raised some other query around medications, prescriptions or appointments. Many viewed potential system overburdening as a barrier to not consulting the GP practice or secondary care service.
Qualitative
Communication of public health messages and community support information
Respondents were generally aware of PHE guidance despite progressive disengagement with media sources throughout the project. However, many found it challenging to interpret the relevance of the advice and consider practical application within their own lives. For example, one student reported,
“many patients didn’t realise they were in the vulnerable group and they’d say, “Oh no I’m not.” Then they’d ask what makes someone vulnerable.’ (2nd yr)
Thus giving tangible patient-centred advice,
“there were a lot of them that didn’t know the advice was to call 111 if they became unwell”, (1st yr GE)
clarifying practical details,
“Questions would be like should I be wiping my post or is it ok if I see a relative who is also isolating. Questions that aren’t as well covered over TV.”(5th yr)
or helping plan for hypothetical scenarios,
“they thought they were sorted but actually they didn’t have a contingency plan for what would happen if say their husband were to become unwell - who would pick up your medication if everyone in your house were to have to self-isolate for fourteen days for example” (1st yr GE)
were perceived by students as particularly beneficial for patients.
Awareness of the community support groups was similarly varied. However patients particularly valued this information given its potential tangible benefits. One reported,
“About 50% of people I spoke to didn’t have support group contacts and wanted them. For example, one lady wasn’t getting any fresh fruit and vegetables because she was depending on a local village store and didn’t know about the support groups that could help her” (1st yr)
whilst another highlighted the psychological reassurance of the community ‘safety net’,
“even if now they have relatives collecting the shopping, they were appreciative that the support groups can be a good backup for if that person becomes unwell” (5th yr)
Medication collection and other health concerns
Whilst patients appreciated the concern around their medications, many raised other clinical or administrative concerns about which they were reluctant to trouble the practice. Students clearly valued their role in ameliorating these concerns,
“I’m doing something that is benefiting patients and as the GPs are so overstretched, it’s not really a service they would realistically be able to provide if they didn’t have student volunteers.” (4th yr)
and the practical utility of mitigating the pandemic’s impact on continuity of care was emphasized by the GP trainee,
“It’s been helpful because it’s demonstrated the impact of COVID on continuity of our standard care. Normally we’d be trying to manage a lot of chronic disease, a lot of hypertension, diabetes, COPD and asthma. A lot of the calls have picked up issues where that continuity of care has been disrupted. Sometimes I can’t do anything about it but sometimes it’s really important it’s followed up.” (GP trainee)
End-of-life care discussions
All students expressed anxiety about discussing end-of-life issues. Whilst those in earlier years of study emphasized the sensitivity and were concerned about their lack of experience or student status and therefore potential impact on the patient,
“it was potentially more sensitive conversations or vulnerable people, kind of choosing the right words for this was definitely a bit anxiety provoking” (1st yr GE)
those in later years were concerned how the remote nature of the conversations differed from the ‘ideal’ way in which they had been taught to conduct them. One fifth year reflected,
“We’d done the communications skills sessions and had all the lectures. That was really different though because the idea of doing it over the phone would be top on the ‘don’t do it this way’ list and calling someone you’d never met before.” (5th yr)
Whilst negative experiences were reported, many related to the challenge of remote conversations, although some reflected communication inexperience. However, the majority of experiences were positive, contrasting with prior expectations. This likely reflected the discretion given to students about the appropriateness of introducing the subject. As one reflected,
“The ones that I asked were all receptive because I didn’t ask the ones that didn’t want to talk to me. About half had already discussed it with their GP or had decided mostly they didn’t want to be resuscitated. The other half, because I explained that it was something we were asking all the patients, were happy to talk about it and made jokes.” (1st yr GE)
GPs and the GP trainee felt it appropriate and beneficial that students discussed end-of-life issues in this context. However, they expressed concern for student wellbeing and ensuring they had adequate support,
“I was conscious that you’re [students] not around collectively in Oxford so it’s not like we can just pop down to the pub for a drink or something to discuss everything. So I was more worried about whether we were going to be able to give adequate support to students who were not used to having those kind of conversations” (GP trainee)
Providing a supportive learning environment for GP and medical student training
All trainees recognized the disruption to their education and wider lives. The majority of students discussed their return home following the postponement of formal teaching whilst the GP trainee reflected on the ‘upheaval in systems, and normal working process [within Primary Care]’ impacting general practice training.
Potential learning was not widely viewed as a motivating factor for participation. Rather students reported a desire to contribute despite their limited experience and a need to fill free time,
“I just didn’t want to feel useless I think. I don’t know about what your year are going through, but our core exam was pushed to September and then it was still being approved and then our ethics and things are going to be open book and everything was just sort of chucked in the air. And meanwhile, I just got this saying ‘would you like to do this?’ and I think it was for me a very welcome project for feeling useful, feeling like we could be of any help at all with our limited experience at the moment because it feels like we are almost a burden more than we are help, you know?” (1st yr GE)
Most students felt their communication had improved, particularly around exploring expectations, tailoring language, using silence, transference, chunking, and sense-checking. Other reported benefits included exposure to clinical topics, learning when to admit you don’t know, and gaining a greater awareness of the broader context of medicine and social determinants of health,
“[participating] reminded me of the wider context of medicine, and understanding people’s social situation, their life situation, and realising that sort of little things like communicating with your friends and your family are so much a part of health as any type of medication or disease” (4th yr)
For students with limited previous patient interactions, there was value in the active ‘doing’ of the project, whereas those in later years emphasized the added utility of real patients over simulated scenarios and the challenge of moving beyond ‘textbook communication’,
“we have communication/skills, which are kind of where they bring in actors and things like that, but I think it’s still very different from when you’re doing it to actual patients. And I think one of the things that I struggled with is when they’re telling you something which is a bit sad or a bit sensitive the response you give to it. I think one of the textbook things to say is ‘I’m really sorry to hear that’ but it doesn’t actually work in all situations/scenarios and I think it was more learning to adapt and respond to people appropriately”( 4th yr)
The GP trainee also reflected how the active coordination of the project helped develop leadership skills for her wider roles within general practice,
“there are all sorts of people involved in the primary care team and so much of what I do is about coordination. What’s been quite interesting trying to look after vulnerable patients is that I have to try and coordinate [students], I have to try and coordinate what the community volunteer teams are doing to a certain extent, a little bit around the medical care for these people and to try and plan strategically how we would cope with things like end-of-life care if that became a large scale issue. I think probably over the project I’ve learnt how better to coordinate all those different things”(GP trainee)
All respondents valued the debriefing sessions, emphasizing the learning potential from feedback, discussion and reflection, but also the social connectivity, which mitigated some of the isolation students were experiencing. Students were also reassured by the prompt responses from the GP trainee if they raised concerns, with some reporting surprise at the level of support offered. This made them feel valued,
“I was pleasantly surprised at how committed [the GP trainee] was to prioritising our Zoom meetings every day […] and I thought it was really, I don’t know what the word is, but I was really happy that she was willing to do that for us in spite of everything.” (1st yr GE)
In contrast, the GP trainee recognized the tacit support offered by her colleagues, but also valued the opportunity for independent development.
Impacts on participants, patients, and GP practice
All participants recognized that the greatest value to patients lay in the social connectivity and sense of self-worth that the calls represented. One student reflected on a bittersweet call,
“I spoke to an elderly lady a few days ago. I was the first person she’d spoken to all day. She was very lonely, and we had a really long nice conversation about all sorts of random stuff […] It was a nice conversation but a bit sad to put the phone down. She sounded sad to put the phone down. She said about 10 times throughout the call she was so grateful for the call and it had perked her up” (1st yr)
whilst another reported the perceived emotional benefit relative to that generated by the wider media,
“I think it’s the sense that they’re worth someone's time even though they’re old. They might have seen things on the news saying they might not get hospital care, so nice to see that they are worth someone's time. (5th yr)
Both the GPs and GP trainee recognized the reduction in overall practice workload thanks to the students’ input,
“It has minimised [the workload], because since it started, the government told us that’s what we had to do but you’d already done it. If you hadn’t, we would have had to do it, ringing through the patients and offering them support.” (GP partner)
and although it increased that of the GP trainee, this was deemed appropriate as trainees do not carry the same patient list burden as qualified GPs.
Whilst the students generally felt well supported, they also reported the personal impacts of the calls. For example, one,
“[thought] about them quite a lot, especially the more emotive ones where you leave and it makes you really sad, like the lady I spoke about earlier who was on her own. I’ve been thinking about calls like that a lot.” (1st yr)
whilst another was more positive,
“Because I’d make the calls in my bedroom and then go downstairs and my parents would ask how they went, and I would say ‘ they were good today’ or ‘I spoke to this nice lady’ so I’d reflect on them for a bit. When a phone call went really well, it sounds really sad, but I’d have this kind of fuzzy feeling for a while after.” (4th yr)