Making a GP longitudinal integrated clerkship in the UK at scale and sustainable - a Realist analysis.

Problem

Longitudinal integrated clerkships (LICs) have had only limited uptake in UK primary care settings and have often been for partial or select cohorts and have often not been sustained. The LIC model of teaching medical students in primary care settings could have important benefits for students’ skills, attitudes and may have a beneficial impact on general practice as their career choice. The UCL “Medicine in the Community” programme in general practice has placed the full cohort 350-390 students in a year-long interwoven GP attachment in the context of a traditional block style curriculum during students’ first full clinical year (Year4), attached to the same GP and sustained over 9 years. The research question is what has made this GP LIC style course work at scale and be sustainable over nearly a decade?

Approach

Using a Realist analysis we developed an initial programme theory and tested it using data from stakeholder interviews (students (n=8), patients (n=13), GP tutors & faculty (n=9)), student evaluations and correspondence to explore “what works, for whom, in what circumstances, and how?” and developed Context–mechanism outcome (CMO) configurations to unpick how a UK GP based LIC at scale can be sustained.

Findings

We developed CMOs which were organised by stakeholder groups with the outcome of a “sustained GP LIC”. For students, mechanisms included continuity with tutors, and receiving high quality patient based teaching, responsive to their learning needs. A negative CMO was the pull of hospital teaching, travelling time & cost to attend general practices away from the central campus. For GP tutors CMOs were receiving organisational support, faculty continuity, and adequate remuneration. Patients were not aware of a longitudinal presence of students but identified their role to “help out” with teaching. Patients wanted to know who students were, and students to interact with them. For faculty, CMOs included multiple schemes (collaborating with HEE, CCGs, training practices and PG Deans) to recruit and retain sufficient GP tutors to sustain the 50 GP tutors needed, needing a presence “at the table” of medical school committees, input to assessment and supportive leadership. The overwhelming negative CMO was the ongoing impact of timetabling clashes. GP Tutors that had come “through the system” as students perceived the course as helping in determining their GP career choice.

Consequences

Realist analysis enabled us to examine this programme as “social systems and structures that are ‘real’ (& have real effects)”. Sustainable “at scale” LIC programmes require high level institutional support, strong faculty/ GP tutor relationships, adequate resourcing and student engagement.