What influences on their professional development do general practice trainees report from their hospital placements? A qualitative study

Abstract Background The clinical learning environment is important in GP specialty training and impacts professional development. Uniquely for GP trainees, about half of their training periods occur in a hospital environment, which is not their final workplace. There is still little understanding of how hospital-based training influences GP's professional development. Objectives To seek the views of GP trainees on how their hospital experience contributes to their professional development as a GP. Methods This international and qualitative study seeks the views of GP trainees from Belgium, Ireland, Lithuania, and Slovenia. Semi-structured interviews were performed in the original languages. A joint thematic analysis in the English language resulted in key categories and themes. Results From the four themes identified, GP trainees were found to experience additional challenges on top of the service provision/education tensions, which are common to all hospital trainees. Despite these, the hospital rotation component of GP training is valued by trainees. A strong finding of our study is the need to ensure that learning from the hospital placements is placed firmly in the context of general practice, e.g. GP placements prior or parallel with the hospital placements, educational activities resourced by GPs during their hospital experience, encouraging hospital teachers to have greater awareness of the educational needs of GPs, including an awareness of their training curriculum. Conclusion This novel study highlights how hospital placements for GP trainees could be enhanced. Further study could be broadened to recently qualified GPs, which may uncover new areas of interest.


Introduction
The clinical learning environment has been described as the foundation of postgraduate medical education [1], with the quality of the training environment correlating to the later quality of care provided by graduates [2]. The challenges of providing such training in hospitals, in addition to the primacy of patient need and service provision, are well described [3,4].
Uniquely for General Practice (GP) trainees, some of this training is in an environment that is not their final workplace, i.e. the hospital, which furthermore may have little understanding of the future professional life of the GP trainee [5,6]. However, the hospital environment has been reported as providing a high prevalence of morbidity to assist GP trainees in learning, and to show future GPs what the hospital can provide in future care collaboration [7]. This model of GP training is standard across Europe ( Table 1).
The rise of competency-based medical education [8] emphasises the workplace as a learning environment [9][10][11]. Earlier publications on the hospital training component for GP trainees have focused on what GP trainees could learn from individual hospital placements [12][13][14]. While the hospital provides experience in the management of acute illness, technical practice, diagnostic procedures [5], in contrast, tolerating uncertainty, awareness of psychosocial factors and patient-centeredness are learnt well in the GP learning environment [15]. In addition, professional identity formation is now viewed as an essential aspect of specialty training [6,13,14], which may be more challenging for GP trainees in the hospital environment where there is occasional denigration of GP or undermining of GP trainees by some hospital specialists [5,15,16]. On the other hand, GP trainees have also reported good peer support in the hospital training and rated hospital paediatrics and emergency medicine as useful [17,18].
This international qualitative project seeks the views of GP trainees of how their hospital experience contributes to their professional development as a GP.

Methods
A multi-country qualitative study, utilising semistructured interviews, was undertaken. The research group consisted of GP trainees and supervisors from Belgium, Ireland, Lithuania, and Slovenia. Ethical approval was granted (or waived) by the appropriate body in the four countries. Belgium; Antwerp University Hospital (20/46 606), Ireland; The Irish College of General Practitioners (ICGP_REC_2020_T15), Lithuania; Not required, Slovenia; Republic of Slovenia Medical Ethics Committee (0120-381/2020/11).

Developing the topic guide
Following a literature search, nominal group technique was conducted with international educators in a workshop delivered at the WONCA Europe Conference (Berlin 2020) [19]. Results were used to develop the topic guide (Supplementary Appendix 1) in English, then translated into Slovenian, Dutch and Lithuanian languages.

Recruitment
Study participants (Table 2) were selected by purposeful samplng to seek a broad range of trainees of different age, gender, prior experience, and country of primary medical degree.
Participation was invited through young doctor's associations, national GP trainee databases, GP trainee social media groups, National Trainee Conferences, and Day Release teaching sites. GP trainees who had less than three months hospital experience were excluded.

Data collection
Nine researchers (GP trainees from Belgium, Ireland, Lithuania, and Slovenia, 1 male and 8 female) conducted the interviews, which were face-to-face or via Zoom V R . The interviews took place between January 2021 and May 2021 and were conducted in the language of GP training in that country. The interviews were recorded and transcribed (by hand or using Otter V R software). The transcripts were anonymised, stored according to European General Data Protection Regulation (GDPR) and imported into NVivoV R software for analysis. Interviews continued until no further new information was forthcoming.   Gender  Female  12  4  11  4  20  Male  6  5  3  2  13  Year of training 1st  4  1  5  2nd  14  1  9  3  18  3rd  4  5  4  4th  4  2  6 Data analysis Thematic analysis, following a six-step process [20], was employed to identify themes and patterned meanings. Data familiarisation of the transcripts and line-by-line open coding of each transcript was conducted by two researchers in each country, supported by NVivo V R (version 12). Initial meetings in each country discussed and refined the codes. Each country's codebook was translated into English. Meetings with the researchers from all the countries condensed the codes and identified key categories and themes. Findings were verified using reflective conversations, comparing and contrasting the codebooks, noting and revising the categories in the light of the research question over several meetings, in line with previously published analytic methods [21,22].

Reflexivity statement
Most researchers are career GPs (range of experience between 1-31 years). Some researchers had previously embarked on a career as a hospital specialist but had changed careers. One of the researchers is on a hospital medicine career. We remained aware that as a research group we may have had a vested interest in promotion of GP as a career and diminution of hospital medicine, and despite our best efforts to the contrary, our interpretation may be biased.

Results
A total of 43 GP trainees participated, Belgium 18, Ireland 9, Lithuania 14, and Slovenia 6. Participants spread over different years of training and gender was split Female: Male 1.5:1 ( Our analysis revealed four themes: 1) supervision, 2) teaching, 3) tension between service delivery and learning, and 4) differing secondary care/primary care paradigms. Illustrative quotes, referred to in the theme discussion, are in Quotations Tables 3-6.

Supervision
The supervision experience was found to vary between rotations, a consistent finding across all countries [ Availability of supervision was highlighted as a significant issue in the hospital environment with concerns for patient safety and trainee well-being as well as training quality. In Ireland and Lithuania, night shifts were noted to have dramatically reduced staffing with a resulting impact on clinical confidence compared to the daytime [

Teaching
One-on-one teaching was particularly valued as teaching tailored towards the future career as a GP, e.g. clear guidelines on when and how the trainee as a future GP should refer a patient to the hospital [ Table  4(4d-g)].
While each national GP training body or institution had a formal curriculum, hospital supervisors rarely referenced it, an experience noted across all countries [   Belgium I also notice that the seminars have become more enriching since there are GP trainees in the hospital because many people have been able to develop a more critical view. I do find it interesting to see how the perspective of the GP trainees, especially in differential diagnostics, has become much broader and that they have much more 'know how' within a certain topic.

Female 2nd
Differing secondary care/primary care paradigms GP trainees noted that approaches to patient care differed in the hospital environment compared to GP. Hospital-based care focuses on completing multiple investigations quickly in contrast to GP where these investigations can proceed more slowly, using time as a diagnostic tool [ Table 6(6a)]. GP training is challenging due to the breadth of what needs to be learnt. This contrasts with the depth of knowledge required for specialist care in hospitals. Some GP trainees felt that their hospital experience immersed them in detail which was more than they needed to know for a future career in GP [Table 6(6c-6e)].
GP trainees valued learning how the hospital system works, providing insight into the patient's journey on presentation from the emergency department through to the outpatient clinics, in addition to the clinical opportunity of seeing the course of an illness [

Main findings
This qualitative study gives insights into the views of GP trainees from different European countries of how their hospital experience contributes to their professional development as a GP.

Valued
It was clear that GP trainees valued their hospitalbased training rotations despite the conditions experienced. This was most noted in Ireland and Belgium. This counters a previous argument by Goldie (23) for situating UK GP training entirely in General Practice.

Identity dissonance
Cruess et al. (2018) recommend adopting the 'communities of practice-theory' as the overarching educational theory in medical education [24]. Each hospital department where a trainee is placed is a 'community of practice' and our research shows that these were not always the ideal training environment for GP trainees. Support of doctors in training should consist of an inclusive welcome to the community, access to activities appropriate to the level of the learner, instruction, role modelling and mentoring, and charting progress through assessment and feedback [25]. This is not consistently present during hospital rotations for GP Trainees.

Unique learning opportunities
Some of the learning on hospital rotations, e.g. current best practice in a specialty, or the full range of presentations which can occur, could not have been learnt in GP. The hospital rotations supported the development of clinical confidence, learning how to work in teams and learning what happens to a patient admitted to hospital. Also, the hospital experience assists in formatting professional connections for those who would practice in the future as a GP in the locality.

Context
An important finding in this study is the need to situate the learning from the hospital experience in the context of general practice. Contact with GP educational supervisors, either through off-site protected half-day release, or through GP rotations early in training, assisted identity formation as a GP and helped trainees use learning opportunities better. Belgian trainees described educating their hospital colleagues on primary care approaches. Cross-education between primary and secondary care by hospital-based GP trainees (with experience in General Practice) could be a valuable opportunity to deepen understanding of each other by both environments.

Supervision
Quality of supervision is the most pivotal aspect affecting the value of the hospital rotation. In keeping with AMEE guidelines [26], the authors recommend that hospital supervisors be aware of the requirements of the training body, and supervision should be structured with regular timetabled meetings [27]. Based on the GP trainee's comments, there is room for improvement in the quality of supervision for GP trainees on hospital placements across all countries.

Strengths and limitations
Strengths of the study include the spread of data collection across four European countries with a range of investment of GP placement time within GP training, from countries with a high proportion (Belgium, Ireland) to countries with lower proportions (Slovenia, Lithuania). Limitations of this study include that the interviews were conducted in four different languages and some distortion of the meaning may have occurred in translation. Individual country GP programmes can be limited by availability of training positions which gives significant heterogeneity and resulting experiences. Another limitation is that the subjects interviewed were all trainees. Widening participants to recently qualified GPs now working in General Practice may have uncovered more recognition of the differences between primary and secondary care. A further limitation is that the COVID-19 pandemic may have affected the responses in our data, as some of the more usual formal teaching was lost and so may be under-reported.

Conclusion
This study shows that GP trainees valued their hospital experience, especially where approachability and availability of hospital teachers improves the quality of supervision. It uniquely shows that GP trainees have additional challenges as trainees in the hospital environment. These include an identity dissonance of being a GP trainee in the hospital environment, shouldering a greater service work administrative burden compared to their hospital specialty peers, and on occasion, being excluded from the community, which should support the learner.