I have been intricately involved with the production and curation of the RCGP’s Essential Knowledge Updates since 2008, first as the clinical lead for the programme, then in a more supervisory role and it has always been one of my favourite projects of the RCGP. Like the College’s Online Learning Environment it’s been growing steadily and currently has now has ca 28000 GP users who keep themselves regularly updated. Unsurprisingly I was rather chuffed when EKU won the Gold Award for Best eLearning Project (third sector) at the annual E-Learning Awards in London. Being picked as the best programme from fifty entries was a huge boost for the amazing team I get to work with and it felt great to attend the ceremony and pick up the award.
So, in an never ending cycle that revolves around Harrogate, Liverpool and Glasgow, this year the great RCGP circus arrived in Harrogate, that loveliest of Yorkshire spa towns. It was great to catch up with friends, colleagues and fellow GPs and do some communal moaning about the state of general practice and engage in some gossiping. There were some amazing talks and presentations, and as usual there is plenty to take back to the surgery. This year I learned:
Maureen Baker, our new chair of council is excellent and the next three years will be cracking
There will be no extra money
Delivering end of life care at home is not only better for the patient but also saves oodles of cash
I am currently working towards a BSc in Psychology at the Open University and to pass this year’s module I have to come up with a piece of qualitative research, so I thought I venture into the exciting world of discourse analysis. But what to do?
Being a German native, I am one of ca 3,396 German doctors practicing in the UK, one of 24,031 doctors hailing from the European Economic Area (EEA) and therefor a member of the 90,639 strong workforce of international medical graduates (IMGs) working in the four nations (GMC, 2012). While I don’t have the number of registered GPs from outside the UK, there is a good chance that there are 15,000+ family doctors who gained their medical degree outside the UK. I know quite a few, as the GP workforce in the East End is a pretty international bunch, which in my view is a good thing. But then, that’s me. In most of my postgraduate training jobs, the majority of junior doctors consisted of IMGs with often senior posts in their country of origin, and the clinical pearls I learned from these colleagues I still use to this day. So why not do some qualitative work on IMGs working as general practitioners in the NHS? I started my literature search and soon drew a blank. There is almost next to nothing out there on either patients’ or doctors’ views on the thousands of IMGs providing primary care in the NHS. There are a few qualitative studies by Ahmad, Kernohan and Baker from the nineties and some quantitative work on patient’s preference for doctors but that seems to be it.
I wonder whether this is a mainly ethical problem, do researchers prefer to stay away from a potentially hot political potato or whether the actual topic is just not of interest? Furnham et al already established that patients prefer seeing doctors from their own cultural background, so it is quite possible that qualitative work asking patients about their perceptions on consultations with IMGs (or asking GPs about their international colleagues) would discover some problematic issues, but should I as an IMG myself shy away from finding out what our patients think of me and my fellow IMGs?
This makes my OU assignment trickier than I thought: not only do I have to negotiate some potentially protracted areas in the ethics section, I am also denied a big bunch of literature to fall back on.
And so I ventured out into the cold night again, to meet my fellow educationalists, geeks, hackers, programmers and online learning specialists at the Moodle Moot. This year held in a non-descript Airport hotel somewhere outside Dublin, it gathered an impressive crowd and as usual featured a wild mix of talks and workshops.
In my role as the medical director of e-learning for the RCGP, I have an interest in both the delivery and the content of our offerings, so it was important to hear from our fellow Moodle providers how they tackled technical, organisational and educational challenges. Nevertheless, the organisers made the same mistake as in previous Moots and did not group talks into streams of similar content but mix sessions so people had to get up between talks and hop from room to room to find the presenters that would deliver something that they would understand (I for once have no idea about the coding and hardware side of things, but am more interested in content, feedback and educational approaches).
Apart from that little dollop of criticism it was highly informative to learn how other educational institutions use Moodle to teach both online and face to face, and how students respond to it.
The Royal College of Surgeons in Ireland have an interesting model of delivering post-graduate and undergraduate courses via Moodle to 4 different international partner colleges. A huge challenge in terms of content creation (apparently they do not adapt their content for the international partner colleges) for the educators who have to create content that spans cultures and different legal structures. Tricky.
It’s quite impressive how a conference dedicated to a Open Source content management system can bring together so may strands of educational life.
Today I signed the ‘All Trials‘ petition. This initiative by some very sensible people and organisations (e.g. Sense About Science, Bad Science, BMJ,James Lind Initiative, the Centre for Evidence-based Medicine) is pressing for the need to register and report all trials, as thousands haven not been reported or registered. For me as a GP this is significant, as I want to know whether the medication I ask my patients to take actually have the reported benefit. Without knowing all the data on a pharmaceutical component I might prescribe something that in a non-reported trial could have done harm (or not work at all). From a marketing perspective it makes of course perfect sense to only publish trials in which a drug showed some benefit, but denying doctors and patients the full extend of a drugs’ effects is surely unethical, hence this very important initiative.
Science is something marvellous. But not only the exploding, whizzing, noisy exciting stuff a la ‘I get paid for pointing at things’ Brian Cox type of stuff, but the other stuff, where people do nothing else but talking to people and take notes. That sort of thing.
Until a few years ago I had never heard of the term ‘Ethnography’. I came across the word in a literature search for a project I was working for and promptly had to look it up. Wikipedia tells me that it’s
“qualitative research method aimed to learn and understand cultural phenomena which reflect the knowledge and system of meanings guiding the life of a cultural group”
Ok. That does make sense. But then I saw this: “Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study”. This was a publication by Swinglehurst et al* in one of last years BMJ that obviously attempted to tackle the tricky subject of repeat prescriptions. This is a difficult subject for every GP practice, as producing repeat scripts most of the time means to hand over the production of a large volume of doctors scripts to a computerised clinical management system and members of staff who are often not clinical trained, but have the whole repeat script thing down to a tee. But how do different practices handle their repeat scripts, what kind of variations exist and what makes them safe or unsafe.
The sheer volume of data Swinglehurst and her team produced is impressive: visiting four surgeries with 41000 patients and recording conversations and processes produced 800 pages of field notes. I am sure that took them a bit to code. Their observations about the different routines across the 4 surgeries was highly enlightening and very valuable for our own practices. I quite like their conclusion:
This research suggests that studying technology-supported work routines that appear mundane, standardised, and automated, but which in reality are socially complex requiring a high degree of local tailoring and judgment from frontline staff, opens up a relatively unexplored agenda for research in patient safety.
Quite concise and to the point. There’s obviously more to study on this subject out there, and it is unlikely to involve Super Nova’s, flesh eating plants, Brian Cox, Richard Attenborough, explosions or loud noises. But that doesn’t mean that it isn’t just as relevant.
Science is like that.
* Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study. Deborah Swinglehurst, Trisha Greenhalgh, Jill Russell, Michelle Myall. BMJ 2011;343:d6788