Overall, 39 GPs participated in this study; of these, 33 were female (84.6%) and six were male (15.4%). The average age was 35.05 ± 5.28 years, with a range of 27 to 47. In this programme, 12, 12, eight, and seven GPs studied COPD, diabetes, stroke, and hypertension care, respectively. Of these, 31 (79.5%) had bachelor’s degrees and 24 (61.5%) had medium technical rank. As a result of the respective availabilities of the supervisors, 14 of the GPs had initially assisted their supervisors’ outpatient consultations and then practiced in the ward, seven GPs had received this training in the reverse order, and 18 GPs had initially assisted the outpatient consultations for a shorter period of time, then practiced in the ward, and then performed the remainder of their outpatient consultant assistance. Although their training orders differed, the total training length was the same for all GPs (nine months), comprising three months in a ward and six months in an outpatient clinic (see Table 1).
Table 1. The trainees’ characteristics.
Training field
|
COPD
|
Diabetes
|
Stoke
|
Hypertension
|
Gender
|
|
|
|
|
Male
|
4 (33.3%)
|
2(16.7%)
|
0(0%)
|
0(0%)
|
Female
|
8(66.7%)
|
10(83.3%)
|
8(100%)
|
7(100%)
|
Age (years)
|
|
|
|
|
< 30
|
2(16.7%)
|
1(8.3%)
|
3(37.5%)
|
1(14.3%)
|
30–39
|
8(66.7%)
|
8(66.7%)
|
4(50.0%)
|
6(85.7%)
|
≥ 40
|
2(16.7%)
|
3(25.0%)
|
1(12.5%)
|
0(0%)
|
Work year
|
|
|
|
|
≤ 5
|
3(25.0%)
|
2(16.7%)
|
4(50.0%)
|
2(28.6%)
|
6–10
|
2(16.7%)
|
1(8.3%)
|
1(12.5%)
|
2(28.6%)
|
> 10
|
7(58.3%)
|
9(75.0%)
|
3(37.5%)
|
3(42.9%)
|
Education background
|
|
|
|
|
Bachelor’s
|
9(75.0%)
|
10(83.3%)
|
6(75.0%)
|
6(85.7%)
|
Master’s
|
2(16.7%)
|
2(16.7%)
|
2(25.0%)
|
1(14.3%)
|
Doctorate
|
1(8.3%)
|
0(0%)
|
0(0%)
|
0(0%)
|
Technical rank
|
|
|
|
|
Junior
|
3(25.0%)
|
4(33.3%)
|
3(37.5%)
|
3(42.9%)
|
Medium
|
9(75.0%)
|
7(58.3%)
|
4(50.0%)
|
4(51.7%)
|
Senior
|
0(0%)
|
1(8.3%)
|
1(12.5%)
|
0(0%)
|
Training model
|
|
|
|
|
O-I
|
4(33.3%)
|
3(25.0%)
|
2(25.0%)
|
5(71.4%)
|
I-O
|
5(41.7%)
|
1(8.3%)
|
0(0%)
|
1(14.3%)
|
O-I-O
|
3(25.0%)
|
8(66.7%)
|
6(66.7%)
|
1(14.3%)
|
Total
|
12
|
12
|
8
|
7
|
O-I: Initially assisting the outpatient consultant, and then practicing in the ward.
I-O: Initially practicing in the ward, and then assisting the outpatient consultant.
O-I-O: Initially assisting the outpatient consultant, then practicing in the ward, and finally assisting the outpatient consultant again.
COPD: Chronic obstructive pulmonary disease
Interview length ranged from 20 to 50 minutes, and the average duration was 30 minutes. Five themes emerged through analysis of the semi-structured interviews. Of these themes, two related to the training pattern, three related to acquiring skills, and one concerned suggestion for improving the course (see Table 2).
Table 2. Themes identified.
Training pattern
|
1. What kind of training did the trainee GPs receive?
|
2. What support did the trainee GPs receive from their supervisors?
|
Acquiring skills
|
3. What did the trainee GPs learn from the programme?
|
4. Did the trainee GPs’ current work benefit from their training experience?
|
Suggestion
|
5. Suggestions for improving the programme
|
Theme 1: What kind of training did the trainee GPs receive?
The full training course comprised three parts: a basic theory class, three months practicing in the ward, and six months assisting the supervisor consultant in the outpatient clinic.
At the beginning of this programme, a four-day class regarding COPD, diabetes, stroke, and hypertension was held. The content of this basic theory class, which conformed with the textbook used in the medical university, ranged from pathogenesis, through diagnosis, to treatment.
After graduation, I seldom opened the textbook because I was too busy. Attending the four-day class allowed me to review the information I had learned in university…
When practicing in the ward, the trainee GPs usually provided care for 2–3 patients simultaneously, like interns, while receiving guidance from their supervisors. During this period, medical advanced knowledge classes or case discussions were conducted once a week, which helped the GPs achieve their training goals.
Supervisor Yang provided me with an opportunity to share a case. My preparation for the PowerPoint presentation involved reviewing the relevant information. As a result of my preparation and presentation, I developed a deeper understanding of the case.
In the outpatient clinic, the trainee GPs observed the methods by which their supervisors handled the outpatients. Meanwhile, the supervisors explained to the GPs interesting cases and answered their questions, which served to improve their skills.
In accordance with the programme syllabus, every Monday afternoon and Wednesday morning another trainee and I sat next to our supervisor and managed the outpatients together. My supervisor asked the patients questions and gave suggestions; meanwhile, we wrote medical records and typed prescriptions. Sometimes, we asked questions and the supervisor gave explanations during the intervals between outpatients.
Theme 2: What support did the trainee GPs receive from their supervisors?
The supervisors’ main responsibilities were imparting medical knowledge and ensuring that the trainee GPs exercised safe medical behaviour throughout the entire training period. Meanwhile, the supervisors also made special arrangements for every GP based on the GPs’ respective abilities and future goals.
Supervisor Xie always allocated simple cases to me because my knowledge foundation was relatively weak and I had less experience in the ward. At first, she checked every treatment plan I made; later, I was able to provide simple, common medical advice independently.
The supervisors also readily answered the trainee GPs’ questions.
If I had a question, I could immediately ask my supervisor. Occasionally, I consulted my supervisor through Wechat (a Chinese chat software). Sometimes, he was too busy to answer immediately, but he would eventually answer, no matter how late it was. Although I have now returned to community health care centre, whenever I have a question I can still immediately consult my supervisor.
Theme 3: What did the trainee GPs learn from the program?
All of the trainee GPs reported that they had acquired comprehensive and advanced skills.
In the past, there was no insulin in our health community centre because of the fear of causing adverse consequences as a result of inaccurate prescription. After receiving training, however, I have become confident in my ability to prescribe insulin. Further, I now know how to adjust its dose to suit patients’ individual situations. With the support of the head of my community health care centre, insulin has now been introduced in our centre, and diabetes patients can now refill their insulin prescriptions here.
In the training programme, I learned for the first time that the pulmonary function test is the gold standard for diagnosing COPD; there are many COPD patients in my community. After spending one month practicing in the pulmonary function test department, I can now not only operate the lung function meter correctly, but also interpret lung function test reports.
Thirty-seven of the 39 GP trainees reported that, as a result of the training, they had learned to handle some complex cases independently.
Refractory hypertension is not uncommon in my community, but before training, I was confused about it and referred patients with this condition directly to tertiary hospital. Since training, however, my recent treatment plans for treating refractory hypertension have all been approved by my supervisor.
Ten of the trainee GPs mentioned that they had learned how to communicate with patients as a result of observing their supervisors.
My supervisor, Doctor Su, usually informs her patients, in plain language, about the extent of their respective illnesses and why they need to be managed. When a patient does not understand, she uses real-life examples to provide explanations. Since returning to my community, I have adopted her method of communicating with patients, and the patients have consequently shown their satisfaction with me.
The majority of the GPs reported that they had made progress in relation to performing differential diagnosis.
When practicing in the ward, I regularly encountered patients with illnesses other than the four targeted diseases. For example, interstitial lung disease is a rare disease in my community, but the experience of learning how to diagnose and treat this disease has broadened my mind and helped me diagnose respiratory diseases such as COPD more confidently.
All of the GPs confirmed that their clinic behaviour had changed from copying prescriptions to making carefully considered medical decisions, and that their basic diagnosis ability had improved.
I used to prescribe medicine by copying the prescriptions provided by patients; this was because I had relatively poor ability to determine patients’ requirements. The patient who left just now has had a cough for half a year; I performed a pulmonary function test for him and found that his FEV1/FVC is less than 70%. After that, I prescribed some inhaled medication (during the interview, the GP showed us the patient’s pulmonary function result and explained why he had prescribed inhaled medication).
Theme 4: Did the trainee GPs’ current work benefit from their training experience?
Firstly, all of the trainee GPs reported becoming more confident as a result of improvements in both their ability to use clinical technology and their communication skills.
As patients could not take CT or MRI examinations in our (community health) centre, before training I did not know how to read patients’ CT or MRI films. After returning to my community centre after the training programme, I began to ask patients to bring their CT or MRI films with them. At first, I could see the doubt in their eyes. I explained the results of the films to them and gave my diagnosis and advice. Eventually, more and more patients began to believe me. One patient told me: ‘Doctor X, your explanation was the same as that given to me by the tertiary hospital physicians’. Now, I insist that patients bring their previous examination results with them.
Second, a two-way referral channel was established between the trainee GPs and their supervisors as a result of the good relationships they had fostered during the programme. Consequently, patients were able to gain access to a continuous health-care service referral system.
Quite a few patients heard I had been trained in the China-Japan Friendship Hospital, and came to visit me. There was a 60-year-old man who, after asking for his symptom and disease history, I thought he had interstitial lung disease; however, I was not 100% sure because some examination results were not available. I asked him to visit my supervisor, and the diagnosis was the same as I had suspected. Now, the patient visits me routinely to refill his medication or adjust his treatment plan.
Finally, the relationship between GPs and their patients also improved as a result of this programme. The GPs’ improved health-care abilities caused patients to develop greater trust in their GPs and to show higher willingness to visit community health care centres.
Before training, I knew that aminophylline and glucocorticoids were administered to COPD patients, but I did not know why or how to use them. As a result, I only copied patients’ existing prescriptions and was afraid to change dosages. In this programme, I systematically learned how to diagnose and treat COPD. The more knowledge I acquired, the more clearly I could provide explanations to patients. I explained in detail why they should use this medication and why they should increase or decrease the dosage. The patients always felt satisfied with my explanations and were willing to visit me again.
Theme 5: Suggestions for improving the program
Seven of the 14 trainee GPs who had initially assisted in the outpatient clinic and then practiced in the ward suggested that it is better to practice in ward before assisting in the outpatient clinic.
When I was in the outpatient department, I regularly felt confused because of my poor knowledge foundation. There were even some patients with diseases I had never heard of, so the knowledge I gained was limited. However, practicing in the ward is a good opportunity to absorb a lot of knowledge in a short time. I believe that I would have achieved more if I had worked in the ward first and then attended the outpatient clinic.
Thirty-five of the trainee GPs suggested extending the time in the ward and expanding the targeted diseases.
Three months practicing in the ward is not enough to greatly improve one’s skills. I needed the first month to acquaint myself with the hospital information system and the rules of a tertiary hospital.
In my community, besides those with COPD, there are many patients with cardiovascular disease. Thus, if there is an opportunity, I hope to also receive training in a department of cardiology.