Phase 5 – The Apprenticeship

KUMEC Teaching Handbook 2016-17

School of Medical Education

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Please refer to the GMC’s guide Tomorrow’s Doctors 2009 for further information.

The General Practice & Primary Care Rotation Summary: (TD9 106) An Eight week placement at a GP practice (full time). It is essential that the student has: Space - to consult alone Computer access - to record consultations and for Internet access to check College e-mails and the Virtual Campus (TD9 19) Time - per week for: Four sessions in direct patient contact consulting on their own - seeing between 3-6 patients per session, a total of 12-24 patients/week. From week 2 students should be given the opportunity to start to consult independently. (TD9 13 & 14) Two sessions on the community studies (1x 500 words and one in depth case study up to 2,000 words) and one obesity case study (500 words) (TD9 22) One tutorial of approximately 2 hours or the equivalent One seminar (face-to-face or virtual) One self directed study session One free session Remuneration: £2400 per student

Workplace Based Assessments

We ask tutors to keep records of student’s attendance and punctuality and sign their weekly diary.

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Key Dates for Phase 5

GP Placements

10 October – 2 December 2016 Rotation 1 3 January – 24 February 2017 Rotation 2 6 March – 28 April 2017 Rotation 3

(Midterm seminars - For students placed outside the M25)

3 & 4 November 2016 Rotation 1 26 & 27 January 2017 Rotation 2 30 & 31 March 2017 Rotation 3

Key Contacts for Phase 5 Monica Martin Phase 5 Community Teaching

Administrator 020 7848 8692 monica.martin@kcl.ac.uk

Ruth Sugden Phase 5 Community Teaching Lead 020 7848 8695 ruth.sugden@kcl.ac.uk

Marion Hill Phase 5 Community Teaching Lead

Assistant 020 7848 8690 marion.hill@kcl.ac.uk

Handbook and policy documents on the website: http://www.kcl.ac.uk/kumec Twitter: @KUMEC4KCL

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Contents The General Practice & Primary Care Rotation Summary: ............................................................. 1 Key Dates for Phase 5 .................................................................................................................. 2 Learning Outcomes for the Rotation ............................................................................................ 4 Phase Five ................................................................................................................................... 5 Learning in General Practice and Primary Care ............................................................................. 5 The first two weeks ..................................................................................................................... 6 Initial Clinical Sessions ................................................................................................................. 7 Learning Objectives ..................................................................................................................... 7 Feedback ........................................................................................... Error! Bookmark not defined. Tutorials ...................................................................................................................................... 8 Troubleshooting ................................................................................ Error! Bookmark not defined. Weekly Community Sessions ..................................................................................................... 10

The Community Case Studies .......................................................................................................... 10 The Obesity Study............................................................................................................................ 11

Weekly Seminars ....................................................................................................................... 12 Midterm Seminars ..................................................................................................................... 12 Assessment ............................................................................................................................... 13

Mini- CEX ......................................................................................................................................... 13 Professionalism report .................................................................................................................... 14 Attendance and Punctuality ............................................................................................................ 14

SSC (ROTATION 2 ONLY) ............................................................................................................ 15 What is an SSC? ............................................................................................................................... 15 OPTION 1 – A Primary Care Topic ................................................................................................... 15 OPTION 2 – Career SSC .................................................................................................................... 15 SSC Assessment: .............................................................................................................................. 16 Administration of the SSC: .............................................................................................................. 16

Signed up activities during the placement .................................................................................. 17 Hospice and Psychiatry .................................................................................................................... 17

ADMINISTRATION at the end of the placement .......................................................................... 17 Phase 5 Contact Details ............................................................................................................. 18 Appendix 1 – Sample timetables ................................................................................................ 19 Appendix 2 – Initial questions to ask students ............................................................................ 20 Appendix 3 – Supplements to the community cases ................................................................... 21 Appendix 4 – Virtual ‘Moodle’ Seminars..................................................................................... 22 Appendix 5 – Mini-CEX .............................................................................................................. 23 Appendix 6a - SSC Marking Schedule .......................................................................................... 25 Appendix 6b – Phase 5 GP Standard SSC Assessment Sheet ........................................................ 26 Appendix 7 – Professionalism Report ......................................................................................... 27 Appendix 8 – Personal Safety ..................................................................................................... 28 Appendix 9 – Student Travel ...................................................................................................... 30 Appendix 10 - Suggested Reading List / Web Resources .............................................................. 31

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“A fantastic rotation where I genuinely looked forward to coming into work each day and actively wanted more sessions! I have learned a lot of medicine and clinical skills, and most importantly I feel that my confidence has improved significantly as a result of the doctors here and the GP placement as a whole. The GP placement is excellent chance to take responsibility and get really involved in patient management. Thanks for a fantastic placement, would wholeheartedly recommend the GP rotation and this practice in particular!” Phase 5 Student

Learning Outcomes for the Rotation

Ruth Sugden Monica Martin Marion Hill

(The Phase 5 Team)

Administer a drug via a nebuliser/ IM injection/inhaler Complete a GP Prescription or Medication Review Set Up & Operate a Syringe

Write a referral letter Explain a procedure to a patient/relative Communicate effectively with another professional….

Take a swab or blood test, fill in the appropriate form, interpret the results and act on them Measure and calculate a BMI and offer nutritional advice Change a dressing/wound care…

Here are a few of the log book sign ups you can do whilst on your GP Placements…but there are more!

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“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” William Osler

Phase Five Phase Five is divided into an eleven week elective and three eight week clinical placements: Medicine, Surgery and General Practice & Primary Care. Each is preceded by campus based teaching. The GP Campus Block introduces students to:-

• what to expect on their placements; • the General Practice consultation; • the essentials of note keeping including the use of the electronic health records; • the management of obesity in a General Practice setting; • the management of chronic disease and minor illessess; • examples of health promotion, multidisciplinary communication and shared care between

Primary and Secondary Care. A variety of large group lecture teaching and small group sessions including simulated GP consultations with trained actors as patients and experienced Primary Care Clinicians as facilitators are used. Final year students should be encouraged to develop an adult learning style i.e. they are self directed and intrinsically motivated with their GP tutor as a ‘guide on the side’, rather than ‘sage on the stage’.

FAQ: “What is expected of a final year student?” The student is not expected to function at the tutor’s level or even at F2 level; the students are not trainee GPs – they are trainee generic doctors. The expectation is that the student engages in improving their own standards of performance towards that of a F1 doctor in August 2017. Students have this handbook and a skills log book which will help guide their learning.

Learning in General Practice and Primary Care (TD9 109) • The named GP Tutor is the main person who co-ordinates the student’s learning and will

provide the majority of the tutorials and feedback. • Daily activities centre on the patients of the practice. The experience of Community

Services will arise through following these patients and researching for the community case studies.

• The placement should provide the student the opportunity to experience a wide range of medical, surgical, obstetric, gynaecological, paediatric and psychiatric etc problems, so that

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they understand when referrals are required as part of the management plan. Managing these patients will help students gain useful practice in therapeutics and risk management.

• The student will be expected to take significant clinical responsibility – under supervision - for the patients they see and sometimes follow up. They will have opportunities to learn and practise clinical skills under the supervision of named primary care health professionals.

The first week (or two) GP Tutors and the practice manager, should orientate the student to the facilities and locality of the practice, as well as draw up a timetable for the 8 week placement (see appendix 1). An initial ‘tutorial’ or induction session to talk with the student about where they are in their training and how well they are progressing is invaluable. It should also include time to discuss expectations - what the GPT expects from the student and vice versa, how they might resolve differences in these expectations in a constructive and supportive way and to discuss the student’s self assessment (online) to look at areas for development. The student will also need to spend some time in reception, to gain a fuller understanding of the role and to meet with all members of the team. Training in the use of electronic patient records should be provided. The student will need to know how to log on, keep notes etc, and will need a ‘Medical Student’ log-in for audit purposes. Learning to record accurate, concise and contemporaneous notes is an integral part of the student’s learning and therefore it is essential that students are allowed to record on the computer. Tutors and Practice Managers should address the following issues during the student’s induction: • Confidentiality and consent • Personal safety • Timetable for the placement, practice activities (a copy of which – including sick leave,

absences and lateness must be retained and sent to the Department) • Signing the educational contract • When and from whom the student can seek help • Who to contact if the student is unable to attend a session due to unforeseen

circumstances • Practice policies for chaperones and home visits • Clinical governance • Emergency procedures and panic alarm • Named supervisor and their deputy if the GPT is away • Where to lock personal items • How to make refreshments and where the rest rooms are etc

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Initial Clinical Sessions (TD9 13)

• Student sits in with the GP Tutor for a couple of sessions to get to know them and so that

the GPT can begin to assess the student’s level of confidence and competence. • Student can sit in with other GPs as well to see a range of consultation styles. • Student gradually gets involved and then begins to take part in the consultation. • Student does consultations with GPT in the room. • By week 2 the student should be consulting independently and in a room on their own, at

all times they need to be able to get the tutor’s attention quickly. A student who feels they cannot gain attention in this way will often feel more exposed or nervous and function less well than one who is confident and has support if needed.

If independent consultations are not happening by the end of week 2, the student or tutor should

contact the Department for advice and help.

Once every couple of weeks do a ‘turn and turn about’ surgery: a shared surgery, when both tutor and student take turns observing each other consulting. The Tutor can see how the student is progressing and is able to offer constructive feedback, the student can see with greater insight the broad range of consultation techniques used by a more experienced doctor and has the opportunity to practice and provide feedback. Videoing consultation sessions is a useful technique to use for feedback.

Learning Objectives Students need to gradually assume responsibility becoming more autonomous in preparation for their F1 post. (TD9 14) Once the student has finished each consultation the GPT must review the case – however briefly – to avoid mistakes and omissions and to provide feedback to the student. No patient should leave the practice without having been seen and/or discussed with a qualified practitioner. Consulting independently, but under supervision from the GP Tutor, can enable the student to develop or fine tune the following skills: (TD9 31) • Taking a focussed history from a patient or carer • Carrying out a focussed examination of the patient • Establishing rational differential diagnoses and able to rank order them • Carrying out appropriate near patient tests • Carrying out rational and cost effective investigations (completing forms and make

appointments etc) • Learning to make meaningful referrals to secondary care or other health professionals • Establishing rational and cost effective management plans, including therapeutics and

prescribing, taking into consideration the role of the whole Primary Health Care Team

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• Explaining to and negotiating with patients and carers on all the above points • Delegating and resuming responsibility appropriately

A placement consisting mostly of passive observation of the tutor consulting will not enable the student to achieve these learning objectives. NB: Students are not allowed to SIGN prescriptions nor spend huge amounts of time generating them.

Feedback (TD9 85) Providing constructive feedback is a vital part of learning. Feedback is most useful if it is immediate or soon after the consultation whilst still fresh in both the student and the tutor’s mind. Students can learn not only from established GPs but also from F2 doctors and GP registrars too. They can share some of their consulting lists, seeing alternate patients and have shared debriefing with the GP tutor about the cases seen. This is a useful teaching opportunity for the registrar practising giving and receiving feedback.

Tutorials Tutorials are an essential and valuable part of the course, consolidating learning, filling gaps and monitoring progress. An early assessment of the student’s learning needs is vital in ensuring that the attachment fulfils their educational needs. GP Tutors need to set aside at least two hours of protected time for tutorials with the student each week, they can be split into smaller sessions but please signpost this for the student (and these are in addition to the ordinary end-of-clinic review). Tutorials should be student led but could include:

• an in-depth analysis of a patient seen that day; • a teaching session on a topic identified by the student or tutor; • a review of current policies or guidelines etc.

Tutorials can be led by other appropriate members of the team and occasionally shared with other learners at the practice. One tutorial should be used to discuss learning from the reflective community cases.

Please contact us if there are any concerns. (TD9 122)

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Troubleshooting (TD9 53) Sometimes students and practice staff raise issues with the Department about the placement and/or learning. Mostly they simply have a question that needs answering or a query they want clarification over. Most of the queries from students are about lack of tutorials, inability to consult independently or perceived lack of organisation in the time table. We are always happy to help. If the issue is serious we will help rectify it. If we feel it is in everyone’s best interest to break confidentiality by talking to the student/practice, we will discuss this with them first. It helps no-one if unsatisfactory issues remain ‘confidential’ and are not resolved in an open and transparent way. If you have any concerns please contact us sooner rather than later. Members of the Department are always available to visit the practice if necessary and will want to meet with student and GPT in an attempt to help resolve any problems. Where it is clear that relations have broken down irreparably the student will be placed elsewhere if at all possible, but this is never our initial response.

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Weekly Community Sessions

The Community Case Studies (TD9 15 & 22)

Phase Five medical students on GP placements are expected to learn how to manage patients in the community with chronic and complex diseases. These patients will usually have input from several members of the multidisciplinary team. Good teamwork and communication are key skills that students can learn and practice as a trainee doctor in Primary Care. Students will demonstrate that they have learnt about the management of patients with chronic/complex diseases and understood the patients’ perspective by writing 2 community case studies (one approx. 500 words and one in depth case analysis of up to 2,000 words). Students may identify appropriate patients whilst consulting independently or may need to ask the tutor to indicate patients that would be suitable. Students have 2 sessions per week for their community studies. At least one session is to meet with the patients and/or carers and relatives and discuss their experiences and management; another is to go on a visit with a relevant member of the multidisciplinary team to learn about their role e.g. the Community Matron to see how they help manage the patient. The other sessions can be used for further visits if useful and relevant for student’s learning or to research and write up the cases. (TD9 22) Below are some questions that students may want to answer in their written reflections:-

Analysis of these case studies by the department demonstrates that students who are actively involved in these processes learn more. So rather than passively observing, students can help do the dressings for example, a medication review or complete a referral form. Students should present the cases to the GP Tutor and at MDT meetings if appropriate and to peers and facilitators in seminars, to compare and share experiences and deepen their learning from managing these patients. The RCGP has awarded a monitary prize for the best community case study each year so please review them and nominate an exceptional case study. For additional ideas see Appendix 3.

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The Obesity Study Medical students need to understand the complexities of the clinical management of obesity. It is a growing concern and presents GPs with a number of opportunities for intervention at key points. As a method of demonstrating this learning students need to complete a reflective case study. (approximately 500 words) At the start of the placement the student will familiarise themselves with the local demography/epidemiology and review the practice and local community’s arrangements with regard to obesity. The student is to make particular note of any conversation where an overweight person is discussed. They should document whether they observed the consultation or whether they raised the issue and if not why not. If they did discuss over weight with the patient was this in relation to the presenting problem or opportunistically? How helpful were the practice protocols or NICE guidelines in guiding the consultation? What referral options were the students aware of and did they make use of them? Campus block teaching including the dietary history ACTS can be a useful tool.

At the end of the placement the student needs to present a summary of their findings and what they have learned. This can be discussed in a tutorial or seminar and has to be submitted to the department electronically. The Driscoll reflective model can be useful to help write reflective cases up. • What? – Description • So what? – Reflection on and of learning • Now what? – Proposed action plan

May I Ask you about your weight?

Do you have any Concerns over your weight? / Are you happy with your weight?

Can you take me through a Typical day’s food and drink?

Do you eat a Special diet?

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Weekly Seminars It has long been known that students who work with their peers fair better in exams Blumenfeld, P. C., Marx, R. W., Soloway, E., and Krajcik, J. S. (1996). Learning with peers: From small group cooperation to collaborative communities. Educ. Res. 25(8): 37-40. The seminar group work supplements learning by allowing opportunities for the student to compare notes with colleagues at different practices, maybe with very different experiences. It is also a safe place to discuss sensitive or contentious issues. Students are expected to bring experiences and their community and obesity cases to share with colleagues. Students attached to tutors who are also seminar leaders, will be allocated to a different seminar group. Where there is more than one student at a practice - each will go to a separate seminar. This avoids potential conflicts of interest. Attendance at seminars is compulsory as they are part of the course and ongoing professional development. Seminar groups allow the student to: • Present interesting and challenging cases to a peer group • Work collaboratively on particular topics • Share individual experiences during the placement • Provide support for each other • Debate difficult or sensitive issues in a protected environment • Practise peer review and receiving constructive criticism • Practise decision-making (including reasoning, bargaining, confronting and avoiding

collusion) through role-plays and group discussion. • Discuss career choices and options. For the students on placements too distant to return to London for seminars, they attend weekly ‘virtual’ seminars (hosted via KEATS – see Appendix 4) and two days of face to face campus based teaching in week 4.

Midterm Seminars Students who attend virtual seminars also attend 2 days of campus based F2F seminars. All these students are expected to attend – see appendix 9. The midterm sessions include: • Psychiatry • GP cases • Consultation practise • Prescribing and Professional Development

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Assessment For further advice contact:

Ruth Sugden ruth.sugden@kcl.ac.uk 020 7848 8695 Marion Hill marion.hill@kcl.ac.uk 020 7848 8690 Monica Martin monica.martin@kcl.ac.uk 020 7848 8692 The students have a logbook of skills to be learned during the year. It is NOT simply a collection of signatures. Please look through to see which skills can be learnt and practised in this placement. In order to be allowed to enter finals the student MUST submit a completed logbook by the end of the year to demonstrate their learning as required by the GMC. At the end of the Phase the student will be examined with two computer-marked papers, testing knowledge and an Objective Structured Clinical Examination (OSCE), where application of knowledge, skills, process and behaviour are assessed. The OSCE includes clinical stations with real patients, simulated patients (actors) and equipment or models. Examiners and the clinical situations tested are drawn from all disciplines, including General Practice and students are marked according to predefined schedules supplemented by significant global marks for attributes such as fluency and ordered working. GPTs are welcomed as OSCE examiners. If interested please contact Ruth Sugden ruth.sugden@kcl.ac.uk.

In Course Assessment

Mini- CEX During the year students can monitor their progress and staff can check learning through the use of Workplace Based Assessments. We use a Modified Mini-CEX (Clinical Evaluation Exercise). Students need to complete at least one per rotation, receive contructive feedback and document, in their logbook, what they have learned. Students are encouraged to complete more than one Mini-CEX per rotation and receive formative feedback to see how they are progressing. This tool, which is used for foundation trainees, is brief (takes 15-25 mins), observed in real time and focuses on a particular aspect of the clinical encounter for structured feedback (both written and verbal) - see Appendix 5.

How to do a Mini-CEX – http://www.youtube.com/watch?v=i2HjPyr4Lj8.

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Professionalism report (TD9 35 & 36) The professionalism report is an amended version of the GMC’s Duties of a Doctor, it is a formative assessment helping students to identify their professional strengths and guide them to develop and improve. Please discuss any areas for improvement with the student early to provide them with an opportunity to change. (see appendix 7) The expectation is that by the end of the rotation students have achieved ‘satisfactory’ in all sections. If not, please mark as unsatisfactory or cause for concern and inform Ruth Sugden ruth.sugden@kcl.ac.uk 020 7848 8695. She will then ask to meet with the student. Please complete the form in week eight and submit it on-line.

Attendance and Punctuality

Fitness to Practice Reliability and dependability are attributes of a good doctor, which we measure, in part, by attendance and punctuality. Tutors and patients will have made special arrangements for the student, organising their time and surgery rotas for teaching. It can be extremely annoying if a student fails to turn up. Absence will also seriously affect the student’s learning. If a student knows they will be unavoidably absent or late, they need to inform whoever is leading the session. Punctuality is essential: lateness is a discourtesy to patients, tutors and colleagues and it disrupts the process of any group work, which is unacceptable. Students should aim to attend 100% of the time, but a minimum of 90% of the sessions. Attendance of 75 - 90% should be addressed by the tutor and the student warned that they risk damaging their learning and having an unsatisfactory sign-up. Any student whose attendance on placement is less than 75%, for whatever reason, will be reviewed by the Head of Phase Five and must see their Clinical Advisor to discuss additional support. Please keep accurate records of this. If a student fails to attend for less than 75% of the time the Department must be notified and evidence of attendance provided by means of the journal and the appropriate feedback on the professionalism and Mini-CEX. Students who attend less than 75% can only progress to their final examinations if the Head of Phase Five is satisfied that there are compensating factors. Tutors may wish to discuss individual cases with staff in the Department – we welcome this – 020 7848 8695 (Ruth Sugden). Experience has shown that students whose attendance is poor are at greater risk of failing finals, so it is of paramount importance that poor attendance is picked up and dealt with at the earliest opportunity to avoid this.

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SSC (ROTATION 2 ONLY)

For further advice contact Ruth Sugden ruth.sugden@kcl.ac.uk 020 7848 8695 Marion Hill marion.hill@kcl.ac.uk 020 7848 8690 Monica Martin monica.martin@kcl.ac.uk 020 7848 8692

What is an SSC?

SSCs - Student Selected Components (of the course) are to explore areas beyond or more deeply than the core curriculum and students are asked to do a piece of in-depth work on a topic of their choice. One session per week is time tabled for this in Phase Five. There are two options for this SSC:

OPTION 1 – A Primary Care Topic This needs to be Primary Care related but the format and content can be decided by the student and GP Tutor. What to do The student chooses a topic which they research and prepare for oral presentation to the Practice or Primary Health Care Team. Eg case study, information poster/leaflet, audit. Following the presentation a discussion should take place when the student answers questions put to them by the team. After the presentation the student reflects on what they have learnt from this exercise (this should include questions the student found difficult to answer, any new information that came out of the discussion etc). The whole exercise is written up in 1000 words, it is this that is assessed. If the student prepares a power point presentation this must be submitted with the 1000 word essay.

OPTION 2 – Career SSC This is an opportunity to explore a specialism. The SSC supervisor might be the attached GP tutor another GP in the practice who is a GPwSI or if the student wants to explore a hospital based specialism s/he needs to identify and obtain the agreement of a consultant who is willing to supervise them. The student will meet with the supervisor at least twice, once at the beginning to decide how to plan the SSC and at the end to present, discuss and assess the portfolio. It would be helpful to review progress half way through, when the supervisor might offer some further advice. The portfolio should contain clear: • aims – why you chose this specialism, what did you want to find out? • objectives - what you hope to achieve by the end of your placement? • method - how will you go about finding out more about this subject? • findings - what did you do?

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- Clinical work e.g. consulting with patients, taking part in specialist clinics (antenatal, child health surveillance, diabetic CHD clinics, etc) - Attending outpatient clinics, clinical meetings, ward rounds, imaging, theatre etc - Community visits pertaining to your specialism (e.g. palliative care visits, attending substance misuse clinic, doing minor surgery, etc.) - Knowledge gained (book work, clinical meetings, tutorials, IT learning, etc) - New skills acquired (listed) - Discussions with the GP tutor and hospital specialist – if relevant - about higher degree exams, job prospects, mini specialism, and work/life balance.

• Conclusion - what was learned, how this placement might influence your career choice.

The student collects, in the portfolio, a description of all the activities in which they were involved: case discussions, reports, clinical protocols. The student presents a summary of their portfolio to the SSC supervisor and the team. After the presentation the student reflects on what they have learnt from this exercise (this should include questions the student found difficult to answer, any new information that came out of the discussion etc). The whole exercise is written up in 1000 words, it is this that is assessed. If the student prepares a power point presentation this must be submitted with the 1000 word essay. Students who choose a hospital based SSC must contact the Department of General Practice first to discuss the details. Any self designed modules must be approved by September.

SSC Assessment: Tutors should assess for a variety of activities, breadth of experience, searches that the student undertook, reference material, presentation skills, ability to answer questions and to take on board suggestions. Most of the awarded marks will be in the range of 55-70. We expect only approx. 5% of students to attain exceptional marks. Any marks over 85 or below 40 will need to be supported by detailed comments by the SSC supervisor and will be further scrutinised. GP tutors have historically awarded higher marks than their hospital counterparts and we would encourage consistency and for tutors to reflect on how many good or exceptional marks they have awarded in the past. If we can help you benchmark please do not hesitate to contact a member of the Department.

Administration of the SSC:

• For those students completing their SSC in the GP practice, during week 4/5 the GPT will be sent an email link for marking and submitting the SSC.

• The on-line process is simpler and more accurate, it will not allow the submission of incomplete forms.

• On submission both GPT and student receive a confirmatory email and copy of the marks.

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• Please contact Monica Martin if you do not receive either the initial email or the confirmation as this means an error has been detected.

• Students will be required to upload their work to both the VC and Turnitin. • For further SSC queries, please contact sscphase5@kcl.ac.uk, who will be able to assist you.

Students need to pass one SSC per academic year to be eligible to enter finals.

Signed up activities during the placement Hospice and Psychiatry These two sessions are arranged with other departments and the times, venues, and sign ups are on the Virtual Campus. Currently these sessions need to be attended and ‘signed off’ in the log book. They are in addition to other learning on the placement. Students in practices outside London can to arrange a Hospice Visit locally and attend half a day of Psychiatry teaching as part of their midterm seminars. This year the hospice visit is a half day session and the psychiatry a full day. Students, please make sure you look at the VC and sign up where appropriate.

ADMINISTRATION at the end of the placement The GP Tutor submits online

• Attendance and Punctuality (Mini-CEX confirmation) • (SSC in R2 only) • Professionalism report • Evaluation of the placement/student

The student submits

• 2 Community Case Studies - by email • 1 Obesity Case Study - by email • Weekly journal - by post or by hand • Evaluation – of the placement/practice – online

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Phase 5 Contact Details If any student or tutor encounters problems that they cannot resolve, or would like more guidance on something to do with the course or the exams, please contact the appropriate person in the Phase 5 team.

The Team

Name Title Areas of Responsibility

Working hours

Phone number

Email address

Dr Richard Phillips

Head of Phase 5

Flexible 4 days/week

richard.phillips@kcl.ac.uk

Ruth Sugden

GP Rotation Lead & Deputy Head of Phase 5

Day-to-day running of the course

Mon - Fri

020 7848 8695

ruth.sugden@kcl.ac.uk

Marion Hill

Phase 5 Senior Tutor, Deputy Phase 5 GP Lead

General support

Wed & Fri

020 7848 8690

marion.hill@kcl.ac.uk

Monica Martin

Phase 5 Administrator

Administration

Mon – Fri

020 7848 8692

monica.martin@kcl.ac.uk

The team is based within the Department of Primary Care and Public Health Sciences Division of Health and Social Care Research King’s College London Addison House Guy’s campus London, SE1 1UL Tel: 020 7848 8692

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Appendix 1 – Sample timetables

Student

GP Tutor

9.00

Patient 1

9.00

Patient 2

9.10

9.10

Patient 3

9.20

9.20

“Empty” slot for debriefing student on Pt 1

9.30

Patient 4

9.30

Patient 5

9.40

9.40

Patient 6

9.50

9.50

“Empty” slot for debriefing student on Pt 4

The student must accept that to fit in with surgeries, there may be gaps during the day. These are excellent revision times. At the same time, the tutors should do their best to ensure these gaps do not occur every day particularly if there are no library facilities available.

Student Time Table for GP Placement (sample of a week)

Time

Monday Tuesday Wednesday Thursday Friday

9.00 Consult in tandem with GP Tutor

Community Activities

Consult in tandem with GP Tutor

Community Activities

Tutorial

10.30 Coffee Break

Coffee Break

10.50 Consult in tandem with Tutor

Activities with practice nurse

Consult in tandem with GP Tutor

12.00 Lunch

Lunch and travel to seminar

Lunch Lunch

1.00 Home visits with Tutor

Home visits with Tutor

Antenatal or Child Health Clinic

Home visits with GP Tutor

2.00 Study in library

Seminar Free afternoon Private study time

4.00 Consult in tandem with GP Tutor

Consult in tandem with GP Tutor

5.00

6.00 Break

7.00 Co-op session (one off)

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Appendix 2 – Initial questions to ask students In general students do not want the School of Medicine to pass on information about their past performance. They fear that the teachers might prejudice them and treat them unfairly. However, students do value your interest in them. Before the General Practice attachment students are asked to complete an Initial Self-Assessment form online. This form asks the students to rate themselves, on a 1-5 scale, on how confident they feel in consultation skills, therapeutics, knowledge of PHCT, professional values, etc. This tool may help you begin a stronger mentoring dialogue with the student about their needs and interests, and about any specific skill areas where they need more experience which could be provided in general practice. It also serves as a reminder of key clinical management skills to have mastered by the end of Phase Five. Once completed online the Self-Assessment Form will be emailed to tutors automatically. Be sure to use the Initial Self-Assessment form emailed to you with this discussion. If you have not received this ask if the student has completed it. Here are some helpful questions you might like to ask students once they have settled down and started trusting you. How many years have you been studying medicine? This question will help you to identify students’ previous experiences. Are they on the 4, 5 or 6-year course? Have they transferred from another university? Have they taken a year out to pursue a BSc? Did they have to repeat a year? Or have they taken a ‘gap’ year? In which quartile or decile does your ranking fall? Some students in the lower rankings struggle with their learning. This might be due to physical or mental illness, personal problems or financial difficulties and therefore these students will need a more careful educational assessment at the beginning of the attachment and additional help in some areas. If during the attachment you uncover substantial problems, please contact Ruth Sugden. Please don’t take on the role of the student’s GP or counsellor instead alert the Department so that we can monitor and assist the student. Can you tell me how do you usually learn? Some students have to read the thickest textbooks from front to back trying to understand everything. Others might cram thin lecture notes just before exams therefore failing to read up on questions and problems encountered in clinical practice. Students who use the syllabus to identify topics relevant to the course at the time of teaching and learn throughout the year are probably well adjusted to the course and learning well.

How do you learn a new clinical skill? Some students fail to realise that medicine is learnt through clinical encounters with patients. The analysis of OSCE results of the last few years shows that students do well on clinical examination and technical skills but in comparison, fail twice as frequently on history taking and communication stations. One explanation is that clinical and technical skills are well described in the logbooks and they can ‘cram learn’ in the skills centre before the exam. History taking is related to knowledge of disease and application of communication skills in the patient interview. Mastery needs practice, meaning history taking skills cannot be crammed. Unfortunately, each year we see students fail their finals because they have not realised this basic fact. Do you have any concerns about approaching patients (or even colleagues)? Learning clinical medicine means learning from patients. Students who fail to engage with patients may develop problems progressing. In the first two years learning opportunities with patients are provided. In the clinical years of the course students often need to identify learning opportunities themselves. Many students feel they don’t want to impose on patients and that they are in the way of nurses and doctors. They have difficulties understanding how a ward/hospital functions. Modelling the positive relationships you have with patients will help the student to see patients as partners in their clinical learning.

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Appendix 3 – Supplements to the community cases Some suggestions of other visits/activities students’ might like to pursue to enhance their learning. Community staff can lessen the load on GPs and provide a different perspective. We tell students this may be their last chance to understand and see what other heath care professionals do for patients, before they become doctors. • Home visits with the DN, HV, paediatric community nurse, CPN or Community Matron • Home visits with community physio, OT, specialist HV, community midwife or Clinical Nurse

Specialists. • Pharmacist – in shop/clinic/surgery settings. • Visits to residential homes/intermediate care centres. • Observing voluntary organisations attached to practice. • Domiciliary and podiatry clinics. • Speech and language therapists. • Domiciliary dentists and opticians. • Reproductive and Sexual Health clinics. • Leg ulcer/vascular clinic • Continence clinic • Shadowing a patient on an OPD appt. • Visit to an undertaker/funeral parlour • Learning the role of Social Services in the community • Liaising with all other members of the PHCT. • Child health clinics. • School nurses. • Community support/auxiliary nurses. • Macmillan/palliative care nurses. • Asylum seeker groups. • DUAL and addiction therapists. • Home loans of hospital equipment in the home. • Week end/emergency community visits • Complementary therapy clinics

The hospice and Psychiatry sessions do not count as community visits as they are Compulsory sign ups.

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Appendix 4 – Virtual ‘KEATS’ Seminars

These ‘virtual’ or e-seminars were created for those students who are too far from London to attend weekly face to face seminars. Students need protected time (one 2-3 hour session a week) for their virtual seminars. The huge majority of previous students have found this input invaluable. It creates a sense of cohesion in the group and is helpful in reducing the isolation of being outside London. Seminars aim to help students to learn more about General Practice in depth by sharing experiences, exploring particular challenges and cases with a group of peers by problem solving together. The aim is to supplement the Midterm seminar (face-to-face) teaching they also receive. Virtual seminars: • Compare experiences and obtain an understanding of different practices • Learn from each other by posting interesting cases, problem solving together, working on a

joint project and sharing useful learning resources • Master this VLE (virtual learning environment) • Work in a new team • Produce a piece of collaborative work as a group (to help with revision) • Quizzes for your own assessment/revision

The KEATS seminars can be found here: http://ehealth.kcl.ac.uk/ King’s log-in is needed to access the group. There are five or six groups of approx 8-10 students. Students can 'talk to’ and 'view conversations' by members of their own group only. Students can upload and share learning resources for their patients. Students should aim to access and contribute to the virtual seminars at least once a week. Confidentiality must be maintained within these groups so students must avoid using tutor and patients names. An experienced facilitator works with each group and also views and posts responses with ideas to prompt further/deeper thinking. ‘Attendance’ at all seminars is mandatory. If you have any questions, queries or suggestions please contact Marion Hill on 020 7848 8690 or marion.hill@kcl.ac.uk.

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Appendix 5 – Mini-CEX Phase 5

Modified Mini-Clinical Evaluation Exercise (mini-CEX) Date of Assessment (DD/MM/YY) Student’s Surname / / Students Forename Student’s Year Rotation Assessor’s Registration Number (e.g. GMC, NMC, GDC) Assessor’s Name Assessor’s Email Assessor’s Position: Consultant ST F2 GP Nurse Other (state who) Brief Summary of Case: Setting for Assessment (e.g. A&E, GP Surgery, Home visit etc.): Please score the student on the scale shown. Please note that your scoring should reflect the performance of the student against that which you would reasonably expect at their stage of training and level of experience. Please mark ‘Unable to Comment’ if you feel you have not observed the behaviour. Well below expectation for stage of training

Below expectation for stage of training

Borderline for stage of training

Meets expectation for stage of training

Above expectation for stage of training

Well above expectation for stage of training

Unable to Comment

Medical Interview Skills Physical Examination Skills Counselling and Communications Skills Clinical Judgement Consideration for Patient/Professionalism Organisation/Efficiency Overall Clinical Competence

1 2 3

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Based on this observation please rate the level of overall competence the student has shown: Overall Clinical Judgement Rating Description

Below Level expected of Phase 5 student

Basic consultation skills resulting in complete history and/or examination findings. Limited clinical judgement following encounter.

Performed at the level expected at start of Phase 5

Sound consultation skills resulting in adequate history and/or examination findings. Basic clinical judgement following encounter.

Performed at the level expected of student in Phase 5 - R1 / R2 / R3

Good consultation skills resulting in a sound history, and/or examination findings. Solid clinical judgement following encounter consistent with early Higher Training.

Performed at the level expected of FY1 doctor

Excellent and timely consultation skills resulting in a comprehensive history and /or examination findings in a complex or difficult situation. Good clinical judgement following encounter.

Which aspects of the encounter were done well? What could the student focus on in order to improve? Agreed Action: Tutor recommendations Student’s response

Do you think the student is on track to pass finals at the end of the year? Definitely. Probably. Maybe. Will really have to work hard. No. (please circle) Do you feel this student should progress to their next placement? Yes, I have no concerns. I have some concerns and feel there should be some discussion about their progression.

Student’s signature …………………..………… Assessor’s signature…………………………

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Appendix 6a - SSC Marking Schedule

The following descriptions are provided as an aid to giving grades in this assessment. 40 is the pass mark and marks over 70 are judged to be exceptionally good. Most students will be in the middle of this. Exceptional – Very good although there may be minor slips. Very well written, organised and accurate submission, covering all major aspects of the topic. Evidence of critical evaluation demonstrated by knowledge and understanding of current ideas and controversies. Evidence of achievement of learning objective to high degree. Evidence of reflection on what they have learnt to a high degree. High standard of presentations Very good – Very good with occasional omissions, irrelevancies or minor slips in accuracy. Lacking high quality in one of the above points Acceptable – Likely to be minor slips and omissions which should not be unduly penalised if the overall standard is adequate. Lacking high quality in two of the above points. Borderline – Numerous minor omissions, irrelevancies and slips and/or a few important omissions. Disorganised submission, poor understanding of current ideas and controversies. Poor evidence of achievement of learning objective. Little evidence of reflection. Poor overall standard. Poor – Generally unsatisfactory with a large number of minor errors and/or several more major ones. Numerous omissions, irrelevancies and inaccuracies. Submissions and/or presentation show significant weaknesses. Information lacks structure, is inaccurate and may be poorly focussed. Not done – This should be given for any items not completed for any reason. Students may be disorganised or have more complex problems which need to be dealt with. This grade alerts all those managing the students that there are problems to be addressed Awarding marks – Most SSC marks should fall in the range of 55-70%. Any marks over 85 or below 40 will need to be supported by detailed comments by the SSC supervisor and will be further scrutinised.

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Appendix 6b – Phase 5 GP Standard SSC Assessment Sheet

Phase 5 Standard SSC Assessment Sheet 2016/2017 Student’s Name

___________________________

Module Code & Title of SSC _________________________________

Type: Career/Standard/GP/Self Designed (please delete as appropriate) GP Practice

Continuous assessment of SSC

Exceptional (17)

Very Good (14)

Good (10)

Satisfactory (8)

Borderline (7)

Poor (2)

Absent (0)

Planning, involvement and commitment / attendance. Development of skills / other attributes If career SSC: Ability to engage with the team/dept and with a range of activities

Oral Presentation of SSC (10 minutes) Exceptional

(7) Very Good

(5) Good

(4) Satisfactory

(3) Borderline

(2.5) Poor (1)

Not done (0)

1. Well defined aims 2. Clear logical presentation 3. Understanding of clinical and basic science background / justification of study methodology If career SSC – personal reflections on this career path

4. Critical review of relevant literature 5. Ability to communicate & engage with audience 6. Use of Visual Aids

NB: lose 5 marks if presentation longer than 12 minutes Minus - Marks

Handling questions (5 minutes) Exceptional (7)

Very Good (5) Good (4)

Satisfactory (3)

Borderline (2.5)

Poor (1)

Not done (0)

7. Ability to Interact with audience & manage Q&A session 8. Depth of understanding of chosen topic 9. Understanding of wider issues and contexts If career SSC – discussion on further training, job prospects, life/work balance

Written Summary (1000 words required) Exceptional (20)

Very Good (17)

Good (14)

Satisfactory (11)

Borderline (8)

Poor (2)

Not done (0)

10. Concise & coherent summary of topic including references/bibliography And if career SSC reflections and preliminary conclusions

NB: lose 2 marks if summary above 1200 words Minus - Marks

Marked by: Signature Print Name Date Examined

Examiner 1

Examiner 2

Comments: Grand Total (maximum 100)

NB: Pass mark > 40

Merit > 75

The online assessment link will be emailed to you in week 4 or 5.

Total (maximum 17)

Total (maximum 42)

Total (maximum 21)

Total (maximum 20)

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Appendix 7 – Professionalism Report Satisfactory Cause for

concern Unsatisfactory Unable to

observe 1 Honesty and integrity:

Always honest with patients, peers and staff in professional work (presentations, documentation and communication).

2 Reliability and responsibility: Reliable and conscientious. Punctual. Completes assigned tasks. Accepts responsibility for errors.

3 Respect for patients: Consistently demonstrates respect for patients’ autonomy and dignity. Maintains confidentiality at all times. Always appropriately dressed for clinical settings.

4 Respect for others: Shows respect for patients’ relatives and carers, other healthcare team professionals and members of practice and community staff.

5 Attendance and approach to learning: Full attendance and participation in seminars, tutorials and other learning opportunities.

6 Compassion and empathy: Listens attentively and responds humanely to patients’, relatives and carers concerns.

7 Communication and collaboration: Works co-operatively and communicates effectively with patients and healthcare team members.

8 Self-awareness and knowledge of limits: Recognises need for guidance and supervision. Aware of appropriate professional boundaries. Personal beliefs do not prejudice approach to patients.

9 Altruism and advocacy: Adheres to best interests of patients.

10 Health: Does not allow his/her health or condition to put patients and others at risk.

Overall assessment

STUDENT: ________________________________________________________

PRACTICE NAME: ________________________________________________________ STUDENT SIGNATURE: ______________________________________ TUTOR SIGNATURE: ______________________________________

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Appendix 8 – Personal Safety Safety Students should do everything they reasonably can to ensure their own safety and that of others at all times. Taking care after dark, being sure to get good directions and preferably being accompanied are all sensible precautions. If students are going on a home or other visit unaccompanied they need to make sure someone knows where they are and at what time they expect to be back, they have a charged mobile phone and do not go home straight from the visit. If a student feels uncomfortable about going somewhere they need to inform the tutor. Students must always pay attention to their personal belongings. If (rarely) someone is threatening or abusive, or if the student feels that their safety is in doubt, they should terminate the consultation, alert the tutor immediately, record and report the incident. We recommend that before starting consultations students should have a discussion with the GP Tutor or Practice Manager at the end of which they should know:

• What the practice health and safety protocol is • Where the panic buttons are or what to do to raise the alarm • What the practice alarm sounds like • What response you should expect if you press the panic button • What you should do if you hear an alarm set off by someone else.

Guidance on Home Visits Students will have limited experience of home visits and the associated potential health and safety issues. It is therefore important that ther GP Tutor and the practice staff undertake a general risk assessment of student safety. Normally students would be allowed to do home visits for those patients deemed ‘low risk’. Examples where there maybe an increased risk of violence to health professionals on home visits are:

• Visiting in the dark • Tower blocks • Female doctors visiting lone male patients • Patients with known alcohol misuse or drug misuse history • Patients with previous violent behaviour to NHS workers • Patients with acute psychiatric problems

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Third, fourth and fifth year students are allowed to visit unaccompanied provided a risk assessment as outlined above has been conducted. Students must have a fully charged phone with them at all times and their contact details available at the practice. Students are required to sign out of the practice and inform the GP Tutor and practice staff of their expected time of return. They should not go directly home from a home visit. If they do not return within an agreed period of time, the student should be contacted.

Indemnity Students should ensure they have read the section on indemnity in the Handbook. They should be aware that the School requires that all students have membership of a medical defence society.

Informed Consent The patient’s consent for any involvement in teaching is always carefully sought and it is made clear they have the opportunity to decline without prejudice to their care; the principle of informed consent means that the exact nature and extent of the patient’s involvement should be made clear to them at the outset. If at any time, a patient decides to withdraw, students must treat this courteously, and not take offence; this is a patient-centred approach to health-care. Students should ensure the practice has a visible notice informing patients of their presence.

Permission

Students should not visit or arrange to visit patients without the express permission of the tutor.

Confidentiality The trust that is put in a confidential conversation allows truth, fear and uncertainty to be expressed; breaching confidentiality destroys that trust. It is imperative that students respect confidentiality at all times, whether as part of consulting with patients or learning with colleagues. Students will become aware of the, sometimes, difficult aspects of maintaining confidentiality when working with more than one member of a family. Students should never discuss what they have heard, even anonymously, in a flippant or disparaging manner.

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Appendix 9 – Student Travel

Student Travel Reimbursement • Each case is considered on an individual basis. • Special circumstances MUST be made known to the Phase Five administrator and GP Lead

before the rotation begins and ONLY those discussed and approved in advance of the placement commencing will be granted.

• Phase Five students have been given a choice about the type and location of the general practice to which they will be attached and only reasonable travel is permitted. Students are expected to use student oyster cards and/or purchase season tickets and travel in an economical manner.

• As of September 2016 and based on the present curriculum, students will need to budget for a maximum of £336.00 for the eight week placement in General Practice. Please see above for travel in excess of this amount.

• Students attending midterm seminars may claim for travel costs over £60. Please see above for travel in excess of this amount.

• Reimbursement rates are reviewed annually.

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Appendix 10 - Suggested Reading List / Web Resources The following list, which is not exhaustive, has been drawn up to help the student. These books may be available in the student learning centre. Booton, P. Cooper, C General Practice at a Glance (2013) Wiley Blackwell. Helman. C, Culture, Health and Illness. 5th Ed (2007) Hodder Arnold Jyoti, B. and Hamad, A. BMJ Clinical review: General Practice (2015) BPP Learning Media. London Khot, A. & Polmear, A. Practical General Practice: Guidelines for Effective Clinical Management 6th edition (2011) Churchill Livingstone London Neighbour, R. The Inner Consultation. 2nd Ed (2015) Radcliffe Publishing Ltd Simon, C. et al The Oxford Handbook of General practice. 4th Ed. (2014) OUP Oxford. Stephenson, A. A textbook of General Practice. 3rd Ed. (2011) Hodder Arnold Stephenson, A. Mueller, M. Grabinar, J. Series Ed Prof John Rees. 100 Cases in General Practice (2009) Hodder Arnold London Tavabie, A. Ahluwalia, S (eds). General Practice Speciality Training making it happen. 2nd Ed (2016) RCGP, London. Weblinks: http://learning.bmj.com/learning/home.html Useful learning modules, often with pre- and post-tests, pictures and evidence of completion at the end that can be linked to your learning needs and used for appraisals/portfolios. www.gpnotebook.co.uk Quick reference which includes epidemiology, aetiology, clinical features, management and complications of a wide variety of rare and common conditions www.mapofmedicine.com Guidelines on care pathways for common conditions seen in General Practice includes images, differential diagnosis, signs and symptoms, investigations to order etc. http://guidance.nice.org.uk/ If you’re not following the guidelines ask yourself “Why is this patient different?” “How do my local guidelines differ?” https://www.evidence.nhs.uk/ A search engine using only the highest quality data to help find answers for clinical queries. It also provides GPs with a portal for a Athens password, free BNF app to download and quick access to NICE guidance and pathways. www.patient.co.uk Useful information leaflets on many conditions from A to Z. Do read them before or when you give them to patients. The language is very patient centred and avoids using medical jargon. http://elearning.healthscotland.com E-learning modules (2 hrs): a. "Introducing health behaviour change" b. "Raising the issue of physical activity" www.exerciseismedicine.org "Exercise is Medicine"