Portfolios--attempting to measure the unmeasurable?
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Education, Medical, Continuing↗
Biomedical subjects
D Snadden
Publications and source records attributed to D Snadden.
'When the talking starts': a framework for analysing tutorials.
The drive towards learner-centred learning which will equip doctors for the next century has encouraged the exploration of alternative ways of learning. A fundamental assumption is that a new learning strategy will either fit into existing patterns or trigger changes in the way that teachers and learners talk together. Despite the use of videotaped tutorials within re-accreditation visits in parts of the UK, the literature reveals no currently existing frameworks to analyse these teaching/learning interactions in the general practice setting. In this qualitative study of tutorials in general practice vocational training, a new grounded theory was developed. This study was innovative in its use of audiotaped tutorials as opposed to espoused theories of interaction. The new theoretical framework of Trainer/GP Registrar interactions consists of five categories: 'gaps to be filled', 'listening in', 'quick fix', 'problem solving' and 'talk on'. Each category illustrates whose agenda was met, who triggers the learning issue, time factors, the educational philosophy and the degree of reflection encouraged. The key principle underpinning this framework is that for learning to be effective a range of educational transactions may need to occur. If educational transactions occur exclusively around one point on the framework, the quality of training and opportunities for critical reflection may suffer. This framework may have implications for the analysis by Trainers of their teaching dialogues in the same way that consultation analysis has informed the development of consultation styles in general practice.
Career Choice↗
Portfolio learning in general practice vocational training--does it work?
Reflective learning has been widely addressed as an important learning mechanism in the educational literature. The creation of portfolios has been seen as a mechanism to promote this, though there has been little exploration of the place of a portfolio in general practice training. This study examined the introduction of a model of a portfolio learning strategy into one training region. The model had been developed by previous pilot work. The study explored the model in terms of its usefulness in general practice training and its relationship to reflective learning. An educational facilitator was used to support this introduction. Workshops and written material were developed to disseminate and refine ideas generated in the pilot study. This was followed by visits to trainer/general practice registrar (GPR) pairs over a 2-year period. These visits included semistructured interviews, which were tape-recorded and analysed using qualitative methods. Additional written resources, video and audio material as well as new workshops were designed with the researched participants in order to promote the development of the concepts of portfolio learning. Sixty interviews were carried out over a 2-year period with 44 pairs of trainers and GPRs. This included a total of 27 trainers and 44 registrars. Eighteen pairs were interviewed twice. Two focus groups were used at the end of the project. Portfolios have a place to play in general practice vocational training. They act as a bridge between hospital and general practice. They can be used to develop a learner-centred curriculum, explore difficult emotive concerns and facilitate feedback. They do not suit all learning styles. Their use is determined by a cost-benefit analysis described in this study.
Education, Medical, Graduate↗
Hospital doctors, general practitioners and dentists learning together.
The design, implementation and evaluation of an innovative course on education for a group of hospital doctors, general practitioners and dentists is described. It took place over five 2-day modules spread over 21 months. There were 33 participants and several tutors and external resources. The course was designed around group work and used a learner-centred agenda. Evaluation was by use of the nominal group technique during the course and by open questionnaires after 18 months. The course was successful in stimulating a number of activities and in developing the skills and confidence of the participants. Problem areas centred around the tension between the learner-centred agenda and the participants' need for structure. Courses such as this require good administration, as cohesive and supportive tutors' group, a clear statement of aims, even within a learner-centred framework, and the establishment of clear ground rules to allow the participants to feel safe. Without safety it is arguable that less challenging learning will occur.
Education, Dental, Continuing↗
Freezing to death--the treatment of accidental hypothermia in the Scottish mountains.
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Accidents↗
Rapid prescribing change, how do patients respond?
The cost of prescribed medication is an increasing burden on health care systems. British general practitioners have been encouraged to reduce their prescribing costs through financial incentives within the fundholding scheme. This study reports on one general practice which reduced prescribing expenditure as part of the move to fundholding. Interviews performed with practice staff and patients were analysed and combined with prescribing statistics and questionnaire data to give a picture of the balance between the experience of patients and practitioners. Fifty-three interviews with 17 patients revealed that most were willing to try cheaper treatments and that dissatisfaction was primarily with the communication they received rather than the change itself. Each patient had to decide how to respond to the change in their medication. The decision-making process and the main factors involved are described and discussed. The experience of having long-standing treatment changed can have an impact on the doctor-patient relationship. This was not found to be a large problem and, it is suggested, can be guarded against. Large-scale economies in prescribing are feasible for some practices, and patients will tolerate such changes if attention is paid to sensitive communication.
Communication↗
Portfolio-based learning and general practice vocational training.
This action research project developed a portfolio-based learning system, based around a 'log dairy,' with the trainers and general practitioner registrars of one training region in the UK. For those that found benefit from the system, the diary became an important way of holding all the events of a training year together; a way of looking back, in order to view the progress made, and looking forward, to view potential learning needs. Such portfolios were not found to be effective formal assessment mechanisms because the threat of assessment influenced the type of material collected. The enthusiasm of trainers was crucial in encouraging use of the model. The action research process was fundamental in stimulating explorations of ideas on reflective learning. There remains some resistance to the idea of reflective writing, and in this context, portfolios may be one educational tool for use by some, but which may not be universally applicable. Their development and implementation requires considerable local support through facilitation.
Family Practice↗
Where have all the doctors gone--and does it matter?
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Allied Health Personnel↗
Integrating undergraduate and postgraduate education in general practice: experience in Tayside.
Several forces have resulted in the creation in Tayside of the first formally integrated unit of undergraduate and postgraduate education in general practice in the United Kingdom. Forces that helped this integration included the desire for change, national developments in education, financial support through funds set aside to cover the additional cost of teaching, and a management structure which concentrates on shared leadership. Forces that hindered the integration included uneasiness about ideas for reforming traditional structures, institutional inertia, the complexity of financial arrangements, and tensions over priorities. The experience of managing institutional changes in Tayside has been invaluable and will lead to a more cohesive approach to undergraduate teaching, postgraduate training, and the provision of services relevant to the development of general practice.
Curriculum↗
Changing to generic formulary: how one fundholding practice reduced prescribing costs.
OBJECTIVES: To observe one general practice's attempt to reduce prescribing costs on becoming third wave fundholders through the introduction of a generic formulary applied to all new and repeat prescribing. To assess the impact on patients and prescribing patterns. DESIGN: An observational study using interviews with patients and practitioners; questionnaires for patients and prescribing data. SETTING: One urban general practice with five partners in Scotland. It became fundholding in April 1993. SUBJECTS: 71 searches of the register of repeat prescriptions identified 1274 potential changes in drugs. Questionnaires were sent to a stratified random sample of 280 patients four months after the changes were made; 33 interviews were conducted with 17 patients selected by local pharmacists to represent a wide range of opinion. MAIN OUTCOME MEASURES: Changes in prescribing and response and satisfaction of patients. RESULTS: Of intended changes, 129 (70%) were in place after four months. Thirty three (20%) of the 167 patients who returned questionnaires were "very unhappy," though interviews suggested that this was primarily with the communication they received rather than the change itself. Generic prescribing rose from one in three (37%) to over a half (58%). The volume of treatment dispensed (as treatment days) fell by 67,674 (10.7%), and the average cost per day's treatment fell by 3.1 p from 32.3 p per day in 1992 (9.4%), producing a total absolute saving of 24% (137,712 pounds) over the first year. CONCLUSION: This practice has achieved a large reduction in prescribing costs rapidly. These were tolerated by patients, none of whom is thought to have left the practice for this reason. Great care must be taken to inform patients appropriately.
Communication↗
The field management of hypothermic casualties arising from Scottish mountain accidents.
The purpose of this review is to examine the current literature on hypothermia as it applies to exposure hypothermia of the type encountered in the mountains of Scotland. A brief overview of the problem, illustrated by a case example, is given. The current literature is then explored and then a set of guidelines for mountain rescue personnel is proposed. It is hoped that this article will stimulate debate on the subject to facilitate the development and dissemination of any such guidelines.
Accidents↗
The experience of asthma.
A group of seven asthmatics were identified from family practice, following administration of a questionnaire, as expressing feelings of stigma or pessimism concerning their condition. They were interviewed in depth, using interpretive research methods, concerning their experience of asthma. Interpretive research uses qualitative methods to explore the emotions, feelings and meaning of the event of interest. All the interviews were transcribed verbatim by the principal researcher and analyzed by the technique of immersion and crystallization. The picture of asthma that emerged for the participants in this study gave rise to the concept of a dynamic model to illustrate their asthma experience. The model showed asthma as a continuum from diagnosis to final acceptance. The transition phase included a need to integrate knowledge, experience and self-awareness before progressing to acceptance and control. A mentoring relationship greatly facilitated resolution of the transition phase. Progress along the continuum was accompanied by diminishing fear. Another important theme to emerge was the fact that tiredness and physical limitations were common feelings, irrespective of the severity of the asthma in medical terms. The implications of this research for health workers is that they have much to contribute in assisting asthmatics to gain control over their condition, particularly in respect to understanding what knowledge concerning their condition is relevant to asthmatics and in understanding the potential benefit to asthmatics of a mentoring relationship.
Adaptation, Psychological↗
Asthma and stigma.
A questionnaire was sent to all asthmatics between the ages of 18 and 60 identified from a rural family practice in Southwestern Ontario. The questionnaire measured various attitudes concerning asthma and was used to identify those respondents reporting high levels of pessimism or stigma in relation to their condition. Seven respondents were then interviewed in depth, using interpretive research methods, to explore the experience of their condition and to attempt to clarify the concept of stigma in asthma. The conclusion of the study was that, for the respondents interviewed, stigma was not a major theme in their illness experience and seemed much less important than the current literature and the initial questionnaire results suggested.
Adolescent↗