Medical education, professional learning and action research in the health service : assessment, interventions and future models for General Practice vocational training of senior house officers

摘要

The education of hospital doctors has been criticised because of its large service commitment and poor educational structure, and this particularly applies to the hospital Senior House Officer (SHO) component of general practice vocational training. This study set out to assess the effect of local interventions to improve SHO education. This required the design and application of a system to assess SHO educational posts, a classification of interventions and the use of a local research cycle to determine the effect of interventions applied. The study involved 80 doctors training for general practice, working in 137 SHO posts, at two district general hospitals in Southern England between 1993 and 1999. Established principles of the action research cycle were applied. These linked quantitative and qualitative research on the local problems in SHO education, with design of interventions to resolve these problems, the action of applying an intervention and then further research to determine if the problems had resolved. Quantitative research involved the design, piloting and assessment of an SHO Educational Audit Project (SEAP) questionnaire applied sixmonthly.qualitative methods involved monthly focus groups, interviews and a field diary. Interventions included letters, feedback, facilitated group discussion, interviews, and external visits. Changes were seen in rates of appraisal, teaching, attendance, and contact with GP mentors. An intervention to increase the amount of induction to SHO posts was ineffective. The number of completed action research cycles applied (seven) and duration of the study (six years) exceeded those seen within the existing literature on action research. This study was also the first description of action research in the setting of medical education for SHOs. It was concluded that the action research cycle was a framework in which acknowledged research methods were placed and should not be seen as a method in its own right. The action research cycle links the disciplines of research, learning theory and organizational development. It is a cycle that can contribute to the individual learning of a professional because it gathers evidence of change using research methods rather than intuition and an assumption of change. Action research can be seen as an improved model for professional learning because it provides focused information and feedback. A model for future general practice training at SHO level was also identified from the study results. This was an "elective" style period where the doctor selected several specialities to work within an outpatient or community setting. The model included induction, appraisal and day-to-day supervision, along with regular contact with general practice and the general practice trainer. Other theory generated by this study related to thresholds for behaviour change, achieving enduring change, the three components that contribute to change (setting, intervention and follow up), the types of educational supervisor and an apprentice cycle for learning. The system for assessing the standards of SHO education, the range of interventions and the action research model used in this study are applicable to other similar settings. The outcomes in other settings will depend on local circumstances and have to be determined by further local research with an action research framework. Since completion of this study, new posts for GP education have been piloted and financed by the Director of Postgraduate General Practice Education throughout the Wessex region. Course organisers specifically for SHO education have been appointed for every vocational training scheme in Wessex and have been able to apply the principles of action research using the monitoring system outlined in this study.