Ahluwalia, Sanjiv; (2020) Understanding the relationship between GP education and patient outcomes. Doctoral thesis (Ed.D), UCL (University College London).

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Abstract

This enquiry is concerned with an exploration of the relationship between clinical education and patient care in General Practice. Previous work in the field has highlighted a statistical association between GP training practice status and patient outcomes. The size of the effect of GP training practice status is small relative to the influence of factors such as patient demography, disease burden, ethnicity, and deprivation. The established literature is largely silent on how clinical education in General Practice influences patient care and outcomes. It has been my experience that my work as a clinician and educator is a social practice where learning and working are influenced by interactions between doctors with patients and educators with learners. This study aimed to identify how this influence of clinical education on patient care is mediated. The socio-cultural theories of learning explored in this thesis offer a useful framework for understanding the role of clinical education on patient care. In exploring relevant theories of education, I draw a distinction between those designed to highlight acquisition of knowledge and participation in the workplace and conceive of GP training practices as complex systems in which the interplay between component elements (learners and teachers, teams and organisations, physical materials and resources, and patients) evolves with time. Importantly, engagement with clinical education and the presence of learners has the potential to create opportunities for practices that influence patient care and clinical outcomes. I am attracted to pragmatism as a worldview which is particularly suited for asking real-world questions in often messy settings where context, utility, and practicality have significance in defining methodological considerations. I have used phenomenology as a methodological approach to study the lived experience of GP trainers in understanding the interplay between clinical education and patient care. I undertook a series of semi-structured interviews with a purposive sample of GP educators involved in front-line education and with experience of the assessment of quality of clinical and educational practice. Interviews were transcribed verbatim. Data generated were analysed using the Framework Approach. All data were handled using electronic software. Rigour and trustworthiness were ensured by providing a clear description of the process of data collection and analysis; using electronic software to handle data and provide an audit trail; peer debriefing; and respondent validation. This study identified four overarching themes to describe how engagement with clinical education by GP training practices influenced patient care. These included: influencing through educational standards; influencing through educational leadership; influencing through learners; and influencing through the educational process. The application of educational standards through the process of accreditation was seen to improve patient outcomes. The development of GP trainers as educational leaders and their developing senses of agency were important mechanisms for influencing patient care within the training practice. GP trainers introduced new ways of thinking (engagement with innovation); values (changes to the way training practices learn and engage with patients); and practices (modernised systems and processes). GP trainees influenced patient care directly as well as by influencing GP trainer and practice systems development. The influences of educational ideas, values, skills, and practices were mediated through enhanced communication and consultation skills of clinical and non-clinical staff; reflection on clinical care (with individuals and teams); collectivised learning characterised by safe spaces to share and learn; involving the whole team in clinical education; and team working characterised by a less hierarchical and more open environment. The interplay between learners and their learning environment is far more bi-directional and relevant than often considered in apprenticeship models of training. GP trainees are “change agents” who disrupt the equilibrium of a training practice. Power relations, diversity of communicative interaction, and norms and rules influence how training practices respond to such a disruption to their equilibrium. Traditional GP training is viewed as an apprenticeship model in which there exists a central one-to-one relationship between GP trainer and trainee. This research challenges the traditional view of GP training as an apprenticeship with a one-to-one relationship between trainer and trainer; instead it proposes an alternative view – one in which GP trainees (as learners) enter a complex educational eco-system recast as participant observers and alter the dynamic that exists between differing components of the system. Implications for my work as a clinical educator are explored with reference to policy and practice on the need to enhance learner well-being; the link between GP training and practice resilience; enhancing competency assessment through capability; exploring notions of apprenticeship in GP training; and healthcare education economics. This research makes several unique contributions to the literature. It seeks to make the importance of patient care central to medical education research. The nature of the bidirectional learning is also clarified – GP trainees offer up-to-date propositional knowledge to exchange with GP trainers; in turn GP trainers share their experiential and problem-solving strategies. This research extends the notion that learners actively influence their learning environment and that practice preparedness for disruptive change (not merely from learners) is enhanced by the introduction of clinical education into practices. Training practices are conceived as complex educational eco-systems in which learners are disruptive change agents. Introducing learners changes the equilibrium of the training practice creating new and unpredictable opportunities to learn. This research confirms the importance of learners legitimately entering the learning environment and learning through opportunities arising from the whole educational eco-system.

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