In the early stages of the COVID-19 pandemic, prior to vaccine availability and with many unknowns regarding transmission, some universities suspended student placements in general practice. This decreased the risk of viral transmission but deprived students of clinical learning opportunities and deprived practices of a revenue stream.1 Immersive and experiential learning in general practice is important for training competent medical graduates. In this context, the aim of this study was to explore the views of general practitioners (GPs) teaching in clinical practice (henceforth referred to as GP teachers) on continuing clinical placements during the early days of the pandemic.
Methods
Design and setting
This was a qualitative study using semi-structured interviews with GP teachers in southeast Queensland from June to August 2020. The research was planned to conform with Tong et al’s consolidated criteria for reporting qualitative research.2
Participants and recruitment
Potential participants were GP teachers from three medical schools in southeast Queensland: The University of Queensland, Bond University and Griffith University. Participants were recruited using purposive ‘critical case sampling’, in which potential participants were identified as being able to provide particularly rich and instructive narratives.3 Participants were invited to interview via telephone and email invitations between June and August 2020.
Data collection
Interviews were conducted via telephone or Zoom videoconferencing guided by an interview schedule with several open-ended questions with flexible prompts. The choice of telephone or video interview was provided to facilitate recruitment. Participants received information about the purpose and scope of the study. Consent was obtained verbally. Interviews were conducted by three members of the research team (KJ = 7, JS = 7, NY = 2) between 17 June and 17 August 2020, audio-recorded with permission, transcribed verbatim and de-identified. The questions were used as flexible prompts without constraining the course of conversations.
Data analysis
Thematic analysis was conducted using an inductive and iterative approach employing a provisional template reflecting the main interview prompt questions and emergent themes.4 An open coding system was applied manually to group and sort data. Four researchers (KJ, JS, MH, NY) formed the analysis team and familiarised themselves with the content of all transcripts. KJ assigned preliminary codes to all sections of the data potentially relevant to the research question. Codes were created inductively from the raw data. Data were extracted systematically by preliminary code and displayed within relevant sections of the provisional template. All extracted data were referenced to the participant and line numbers of the transcript. This provided supporting data evidence under each preliminary code to assist with review by the analysis team. The analysis team employed an iterative process of review and refinement of codes and collation into potential themes until no further insights presented.
Template categories were refined into a matrix of four main themes. The final coding framework was hierarchical, with second- and some third-order subgroup codes distinguishing between cases. Dissenting data were highlighted and re-examined for further insight. Reflexive writing of the emerging story of the data continued throughout the analysis, along with iterations of a visual concept map showing the relationship between themes and main codes. Preliminary interpretation of findings was presented to the wider team. Further review and interpretation (with reflection back to the codes, extracted data and transcripts) were provided through peer debriefing with the wider study team to enhance the interpretative rigour of the study (KAW, DAA, NS).
No participants accepted the invitation to review their transcripts. To offset the lack of participant checking and minimise bias, the coding and triangulation was conducted by researchers with years of experience as clinical and academic GPs, supervisors and teachers.5 Researcher attributes, questions, relationship with participants and method of data collection influenced the process of enquiry. However, reflexivity was enhanced by the different expertise and experiences within the research team. Within the research team, KJ is an experienced qualitative researcher with a background in public health, health service planning and nursing; KAW, JS, NY and NS are academic and practising GPs with experience in qualitative research; MH is an academic GP; and DAA is an experienced primary care qualitative researcher.
Ethical approval was granted by The University of Queensland (2020001164) and Bond University (36318031).
Results
Fifteen GP teachers were recruited from 14 practices (80% male; 60% >20 years in practice), some of whom had clinical placements suspended. Interviews lasted 21 minutes on average (range 14–33 minutes).
Four interrelated themes emerged from the data: expecting clinical teaching to be continued, challenges and concerns, new opportunities for student learning and contribution, and university support for clinical placements in general practice.
1. The GP teachers expected that clinical teaching in general practice would be continued.
I was very surprised … when … the University said ‘stop’… I couldn’t understand why they stopped [students] coming to general practice ... [Participant (P)02]
I felt it was our duty to just keep teaching, that that’s part of medicine. And actually the whole point of medical teaching is it’s kind of live teaching and if the current life situation is a pandemic, that’s where you get taught. [P03]
A great learning exercise for them to actually live through a pandemic and have all the public health measures that are coming out. [P09]
They’re learning general practice but in a very different way, just as we’re all learning how to consult with patients, you know, over the phone and what is safe and not safe to do. [P10]
2. Challenges for GP teachers included resource constraints.
We didn’t have enough masks, you know, at that point. There was a huge shortage of stuff. So, I knew I needed to save up the masks for the times I had an unwell patient. [P06]
GPs just couldn’t take students because the rooms were too small … the four square metres rule precluded having three people in a consult room. [P11]
We were really having to conserve PPE [personal protective equipment] and so the students perhaps missed out on those opportunities ... [P16]
Concerns centred on infection control, medicolegal liability and student learning.
It was in a medicolegal sense, that if a student had got [COVID-19], was I vulnerable in some way to some sort of accusation of malpractice or not caring for her appropriately? [P06]
I did feel very sorry for him because obviously I had so much on my plate that to be honest the medical student got shoved down the list of my priorities. [P10]
The introduction of telehealth also created challenges.
I think that with telehealth it’s become more stressful taking students. I found [myself] being much more exhausted after a session with students. [P02]
I just felt it was really hard to engage the student. [P08]
It’s actually much harder to do telehealth. It’s
actually very draining. It’s a really hard slog, yeah, and all the extra admin side … Trying to evaluate people on the phone and go, ‘Okay, this is someone I actually need to see face to face’. [P10]
3. Telehealth also created new opportunities for student learning, including more time for reflection and looking up guidelines and resources, increased access to sensitive consultations, and opportunities for thinking-through rather than doing examinations.
[Video is] a great opportunity to think laterally about examination and then figure out ways they can do it differently … you can see the cogs kind of turning, see them thinking instead of doing a rote-learned examination. [P05]
The odd mental health patient that doesn’t want a medical student there seems to have not had a problem when it’s not someone that they have to make eye contact with in the room. [P03]
Telehealth are slightly quicker consultations, so we probably had more time for debriefing after each consultation. [P09]
It did increase the time we spent with students on communication skills. Your communication skills have to be a lot more finely tuned … may even increase student’s communication skills. [P11]
What resources they should use … like eTG [Therapeutic Guidelines]. And we were going through different topics … the Red Book [The Royal Australian College of General Practitioners’ (RACGP’s) Guidelines for preventive activities in general practice] and the White Book [RACGP’s Abuse and violence: working with our patients in general practice]. … I think some of these books and guidelines are a bit daunting and actually showing them how to use them correctly is helpful. [P08]
The pandemic also created new opportunities for students to contribute to the practice, including assisting with administrative tasks and acting as a conduit for information.
I think it was an advantage for both them [students] and an extra pair of hands for us to actually cope with the situation. [P13]
Our student … was incredibly engaged and worked with our team … implementing a lot of the public health recommendations and communicating and upskilling staff. So, he really was an integral member of our team and quite involved with that process. [P16]
4. To support clinical placements, GP teachers wanted clear communication and guidance from universities and for students to be trained in infection control and telehealth skills.
Guidance early on as to what was appropriate for the student or whether there was any sort of restrictions around what they could be doing. [P16]
A student actually was sick at one stage, and so we had to say, ‘You can’t be here, you can’t come back until you’re completely well’. [P10]
I think having the students skilled and being able to don and doff PPE is helpful. [P16]
The university actually sent us out some PPE too, which was much appreciated. [P05]
[Telehealth] is a skill that we need to learn and develop, but I don’t think the students have been taught that … certainly the students I’ve got, they’ve got no idea how to do it. [P02]
Conclusion
Findings suggest that many GP teachers want to, and can be supported to, continue clinical placements during an evolving crisis. The pandemic created challenges for GP teachers, including resource constraints, increased administrative burden and adapting to telehealth, but also new opportunities for students to learn and to contribute to the practice.6–8 Students can be an extra pair of hands to assist with administrative tasks, source the latest public health COVID-19 guidance and support public health measures in practice, including contributing to PPE protocols and skills. GP teachers identified new opportunities for student learning during telehealth consultations, including increased time for reflection and looking up guidelines and resources, increased student access to sensitive consultations, and opportunities for students to think-through rather than undertake physical examinations. Strengths of this study include that it was conducted in the early days of the COVID-19 pandemic with GP teachers associated with three universities. Limitations include that some practices had placements suspended, which may have influenced GP teacher views. In conclusion, while the early stages of the COVID-19 pandemic presented many challenges for general practice, GP teachers remained committed to teaching and identified new ways to enhance student learning.