Future capacity for expert generalist care: a critical view of European training Presented by Alice Shiner, Jessica Watson, Greg Irving, Joaane Reeve at WONCA Prague 2013

1. DR ALICE SHINER
DR GREG IRVING
DR JESSICA WATSON
DR JOANNE REEVE
PROFESSOR AMANDA HOWE
R C G P J U N I O R I N T E R N A T I O N A L C O M M I T T E E , U K
W O N C A W O R L D C O N F E R E N C E , P R A G U E , J U N E 2 6 T H 2 0 1 3
Future capacity for expert
generalist care: a critical view
of European training

2. Expert generalist practice
Informed by a view of the whole; defined by 2
elements:
• Principle of PERSONALISED DECISION
MAKING, supporting personal illness care
• Practice of INTERPRETIVE MEDICINE: critical
use of range of knowledge in dynamic exploration
and interpretation of individual illness experience,
including capacity to judge trustworthiness
(Reeve 2009)

3. Objective of study
 To explore international colleagues‟ views about how
and whether training prepares them for expert
generalist practice (EGP)
 To ask the question:
“To what extent is expert
generalist practice normalised
into GP training across Europe?”

4. Methods
 Two focus groups, conducted at the 2012 RCGP
Annual Conference
 Participants: 14 trainees/newly qualified GPs from
12 Wonca European countries
 Because EGP is a complex intervention the interview
schedules and data analysis were informed by the
“Generalist Capacity Assessment framework”
developed using Normalisation Process Theory
Sense making Engagement Action Monitoring
 Data analysed using „Dedoose‟ online software

5. Results: Sense-making
 Trainees recognise the EGP role as one of
“interpretation” and knowledge integration
 They drew comparisons between EGP and the role
of the specialist
 Practice often viewed as “intuitive” and enhanced by
experience, but not as “expert”; leaving trainees
fearful of defending practice against external
scrutiny

6.  Evidence of participants implementing, continuing and
even making changes to training to support EGP in the
face of adversity (e.g. long hours)
 Strong feeling that EGP requires continued practice
 And that personal motivation matters
 BUT external engagement was missing, with the
perception that both other doctors and the wider health
system fail to recognise the importance of EGP
Results: Engagement

7. Results: Action
 Most stories were about being an „all-rounder‟, but
some were about the practice of EGP
 The prime resource used to „do‟ EGP was
experience (i.e. seeing patients)
 Other resources were role-modelling and peer
sharing
 There was little discussion about the boundaries
and wider practice of the EGP role, e.g. how it
fitted in with team-working

8. Results: Monitoring
 Evidence that participants considered EGP
worthwhile and evidence of continuous
investment into person-centred practice
 Most training involved feedback and
reflexive appraisal, however there is room
for more critical reflection
 External monitoring focuses on
financial/biomedical priorities and if
anything constrains EGP

9. Conclusions
 Trainees recognise EGP role as one “interpretation” and
knowledge “integration”
 Committed to and continually invest in EGP
 Make sense of EGP by comparison with specialist
 Room for more critical reflection
 A lack of training in the critical judgment of interpretive
practice

10. Limitations
 Small sample, several countries missing
 English was second language for all participants
 How much did participants understand what we
meant by EGP?

11. How this fits in
 Forms part of a wider study examining the practice of
generalist expertise (Reeve et al 2013)
 Highlights gaps in service design limiting development
and implementation of EGP
 Australia: Gunn et al (2007)
 What is the place of Generalism in the 2020 primary care
workforce?
 UK: RCGP Commission on Generalism (2012)
 Calls for extended and enhanced training

12. Recommendations
 Sense Making
 Awareness raising campaign (inside and outside of profession)
 Compare “All-rounder v EGP”
 A “summit” bringing key stakeholders together
 Engagement
 Experiential learning: Medical school / GP training / CPD
 Whole system approach to prioritising EGP

13. Recommendations
 Action
 Curriculum review
 “selectively gather and interpret information”….but how ?
 Focus on areas at the boundary between Illness and Disease
 CPD for Interpretive Medicine
 Monitoring
 Blueprinting EGP learning outcomes to assessment
 Focus on WPBA and CSA
 Tools needed to support critical reflection for trainees