Abstract
COVID-19 has had a significant impact on trainees throughout the country. As GP trainees, we have had to develop new skills and adapt the way in which we work in a very short space of time. As of 19 August 2020, the total number of COVID-19 cases in London was 37 610, with a total number of deaths standing at 6153. An additional 232 have had COVID-19 recorded on their death certificates (Mayor of London, 2020).
In April 2020, trainees in my hospital were redeployed to a COVID-19 rota, working 12.5-hour shifts over 3 days followed by a break of 3 days. Foundation Year doctors, core surgical trainees and GP trainees in surgical specialties were deployed to medical specialties. GP trainees in paediatric placements were reassigned to the Intensive Treatment Unit (ITU). GP trainees in general practice and psychiatry were not redeployed, but the roles in the teams changed.
As a GP trainee, one of the initial challenges was the withdrawal of face-to-face teaching. Prior to the pandemic, I enjoyed meeting my fellow trainees and sharing experiences. Initially, formal teaching was halted, but we continued throughout this time to have small group discussions using Microsoft Teams. In these sessions we debriefed interesting or difficult consultations or cases we had come across during the week with fellow GP trainees and a Programme Director.
Looking to the future, I wondered what impact the pandemic would have on GP training. To help answer this, I conducted a survey of trainees to better understand their experiences and to garner their thoughts on how training could be improved.
How did I gather information?
I conducted a questionnaire survey of GP trainees within my Vocational Training Scheme (VTS) scheme between 12 May and 9 June 2020 using Smart Survey. The survey had 15 questions that were a mix of multiple choice questions and free text answers. I disseminated the survey by email and WhatsApp messaging.
What were the experiences?
Thirty GP trainees responded to the survey. Of those, 40% had been redeployed. Of those who were redeployed, 25 (83%) reported being well supported by their supervisors.
The trainees reported that the workload had either decreased or had not significantly changed during this time. The majority of trainees within general practice continued to receive teaching from their GP tutors (Figure 1). After a short period of time, teaching had resumed in addition to the small group discussions. Teaching was delivered in a virtual format via Zoom enabling trainees to log in and listen to the training.
If in general practice – did you receive tutorials from your trainer?
Trainees in hospital practice reported being more confident in having discussions with patients and their families about do not attempt resuscitation (DNAR) and advanced care planning. From personal experience, these differed because the majority of the discussions happened over the telephone; not something we were used to.
In general practice, some trainees reported being more confident handling teleconsultation skills and learning to triage patients over the phone. Moreover, by needing to become innovative, some trainees said they had developed leadership and management skills. GP trainees within our scheme worked hard to engage with those in charge to deliver improvements in practice.
The challenges trainees reported included handling more complex consultations (including doing the 6–8-week baby checks) and consultations with patients with learning disabilities. Some trainees were concerned about their readiness to complete consultations within the allocated 10–15-minute appointment times.
Trainees in the hospital were concerned that training opportunities had become limited. This was noticeable among those who had been redeployed from a surgical specialty to the medical wards, and from paediatrics to proning adults on ITU. As a result of the emergency rota, it meant that many GP trainees in medical specialties had fewer opportunities to clerk patients. It also became a challenge to have meaningful clinical supervision with hospital consultants because of moving to different wards, and for some, to different specialties. Many trainees felt that it had been harder to complete portfolio requirements (Figure 2) and that training had reduced as a result (Figure 3). A similar perspective was noted with psychiatry trainees, whereby owing to their roles changing, training opportunities were reduced.
Has it been easier, about the same or harder to complete portfolio requirements? Have you felt you have had more, less or about the same training as pre-COVID?
What did the pandemic teach us?
The survey highlights that GP trainees can empower themselves to improve their training experiences. By presenting the survey results to services and positively engaging with clinical supervisors and programme directors, we were able to make small improvements to our training experience, including the initiation of extra teaching sessions within the VTS academic year.
We demonstrated the potential of technology in medical education using virtual teaching sessions. This allows trainees greater flexibility in accessing training and allows teaching sessions to be recorded and viewed at other times.
Working patterns for doctors changed during the pandemic. We worked with the hospital to ensure that when rotas were de-escalated, we were given priority to stay on the wards we had been rostered to. Going forward, GP trainees should be given similar training opportunities to their counterparts in their respective specialties when rotas are being planned.
What may have attributed to an initial decrease in workload was the number of doctors deployed to hospital wards and medical clerking teams; these were initially extremely well-staffed to cope with the number of COVID-19 patients being admitted. Trainees in general practice felt their workload initially decreased in the early weeks of the COVID-19 pandemic because of changes to methods of consulting and patient demand. This changed during subsequent months and the workload increased.
We learnt that GP trainees felt it was harder to complete portfolio requirements during this time. The RCGP issued guidance during the pandemic explaining that portfolio requirements had reduced but there has been concern at Annual Review of Competence Progression (ARCP) to show evidence of curriculum mapping.
For ST3 trainees about to gain their certificate of completion of training (CCT), there was concern about their preparedness to practice as GPs. This has been raised with the Head of the School of General Practice for North Central and East London. She advised that the RCGP and Health Education England (HEE) have offered flexibility in extending training, but it was also highlighted that there is the option of a GP Salaried Portfolio Innovation Scheme (SPIN), which offers salaried GPs opportunities to undertake sessions in other areas to boost their professional development. Crucially, these GPs would have access to peer-support sessions facilitated by an educator. The aim would be to provide support to practicing GPs and trainees wishing to explore this option (NHS England, 2020).
The results suggest that trainees are able to influence the way in which general practice moves forward. We should be part of the conversation on future developments in training and how we consult with patients. This includes whether standard face-to-face 10-minute appointments should be the default method of consulting. We might advocate teleconferencing or video consultations, and be more involved in implementing and improving these new ways of consulting.
Limitations
The survey took place within one metropolitan VTS scheme. Opinions from other schemes would be helpful to reflect the experiences of GP trainees in other areas.
Summary
General practice training has been affected by COVID-19. With no certainty of how the pandemic will progress, it is imperative we make the most of our time as trainees. As advocates for our training and working with our GP colleagues, I believe that as trainees we should be optimistic and fully engaged in shaping our training in general practice.
