GP ASSISTANTSHIP STUDENT HANDBOOK 2020 - 21

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GP ASSISTANTSHIP

This handbook should be used together with the Academic Regulations and the Student Guide. It provides information specific to Barts and The London School of Medicine and Dentistry (SMD), while the Student Guide gives information common to all students of the College.

The Academic Regulations provide detailed information on all aspects of award requirements and governance.

NOTHING IN THIS HANDBOOK OVERRIDES THE ACADEMIC REGULATIONS WHICH ALWAYS TAKE PRECEDENCE.

The School's handbooks are available on QM+.

The Student Guide is available from the SMD Student Office; the Student Guide and Academic Regulations are also available on-line at:

www.arcs.qmul.ac.uk

The information in this handbook was correct at the time of printing. In the event of any substantial amendments to the information herein, the SMD will attempt to inform students of the changes.

The College cannot accept responsibility for the accuracy or reliability of information given in third party publications or websites referred to in this

UNIT OVERVIEW

1 For students on two three-week placements see details under assessment section

INTRODUCTION

The GP Assistantship:

Our overall aim is "to help all students to become better doctors, irrespective of their current career preference or eventual career choice." Renaming the placement, the GP Assistantship we are stressing the importance of students being actively involved in patient care as members of the clinical team.

We aim to ensure you become immersed in General Practice and Primary Care in all its facets and develop independent practice whilst learning good medicine in that context.

The focus is on THINKING AND ACTING LIKE A GENERALIST: by the end of the 9 weeks you should be able to assess undifferentiated acute and chronic presentations and negotiate a safe management plan with the majority of patients – always with supervision. We hope you will find it an interesting and stimulating experience. The General Practice placement is an integral and compulsory part of the curriculum.

LEARNING NEEDS

You should use the specific learning outcomes in the student guide and other core documents from Year 5, including the practical procedures log book, to guide learning. If you have not already done so, you may find it useful to read the document “Outcomes for Graduates.”¹

INTRODUCTORY TUTORIAL CHECKLIST

You may find the following check-list helpful for use during the Induction session with your GP Tutor:

• House Keeping - important practical details about working in the Practice, things to do and not to do, how you can contact the Practice and Tutor if you are delayed or ill (such as mobile numbers or bypass phone lines)
• Learning Agreement & Learning Needs Assessment: ensure both you and your GP Tutor have discussed responsibilities
• Timetable - an outline of the schedule during the placement. Including ‘We must talk about covid’ session
• ‘We must talk about Covid’  Discussion with GP Tutors about impact of Covid on their clinical work. Expectation setting. Discussion about placements during Covid – PPE, Social distancing, what to do if you become unwell.
• Assessments - what your are expected to complete, and when this should be done.
• Learning opportunities at the Practice - this may include GPs with Special Interests, Protected Practice Learning times or teaching sessions, special Community Clinics, and Nursing Home ward rounds amongst others.
• Log Book of Practical Procedures and Clinical Skills - go through this with your GP Tutor and agree the best approach to covering the relevant procedures and skills in Primary Care.
• Specific Learning Needs and Outcomes - discuss your learning needs and consider the learning outcomes specific to this placement. This will help inform Tutorials and Self-Directed Learning time.

1.General Medical Council. Tomorrow’s doctors. Outcomes and standards for undergraduate medical education. London: General Medical Council; 2009. Available from: http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

AIMS

"To help all students to become better doctors, irrespective of their current career preference or eventual career choice".²

By the end of the 9 week Assistantship students should be thinking and acting like a generalist: be able to assess undifferentiated acute and chronic presentations and negotiate a safe management plan with the majority of patients – always with supervision.

We aim to provide an immersive placement in General Practice and Primary Care in all its facets, and to help students experience independent practice whilst in a safe learning environment. Students should be included in the practice team and have every opportunity to assist the team in real patient care with training, support and supervision.

2. Fraser, R C. (Ed.) Clinical Method: A General Practice Approach. Second Edition. 1992

SPECIFIC OUTCOMES

I) Knowledge

II) Skills

III) Attitudes

I) KNOWLEDGE

You will be expected to acquire clinical knowledge in areas of medicine particularly relevant to community-based practice. The following list is not exhaustive or exclusive, however can be used as a guide during the placement.

HEALTH PROMOTION AND ILLNESS PREVENTION

• Identify the benefits and problems of early or pre-symptomatic diagnosis.
• Understand the need to identify high risk groups in General Practice.
• Consider the importance of Health Education in Primary Care.
• Consider methods of Disease Prevention and Health Education within the Community setting including screening.

DATA GATHERING AND DECISION MAKING ³

To acquire assessment and management strategies for the following common issues:

• Common symptoms and presentations (e.g. back pain, abdominal pain, headaches, chest pain, vaginal discharge, lethargy, dizziness)
• Common infections (e.g. respiratory tract infections, viral illnesses of childhood, urinary tract infections)
• Ischaemic Heart Disease, Hypertension and Heart Failure
• Asthma and COPD
• Depression and Anxiety
• Osteoarthritis
• Common skin conditions including Eczema and Psoriasis
• Diabetes and Thyroid Disease
• Routine Antenatal care
• Demonstrate counselling for different contraception types, and Termination of Pregnancy.
• Understand special concerns and considerations around sub-fertility and describe referral options.

Also, to include acute and new presentation in primary care:

• Cardiac pain
• New onset Diabetes Mellitus
• Shortness of Breath
• The Unwell Child

MANAGING MEDICAL COMPLEXITY 3

·       Enable people living with long-term conditions to improve their health

·       Learning to manage multiple health problems within an individual patient

·       Adopting safe and effective approaches for patients with complex needs

COMMUNITY ORIENTATION (Including OOH and Palliative Care)

·       Understanding the health service and their role within it

·       Build relationships within the communities in which they work

• Understand the role of Informal Carers in the community.
• Understand the relationship between Primary Care, Secondary Care, Social Services, and the Voluntary Sector.
• Compare and contrast the differences between General Practice and Hospital based practice.

OUT OF HOURS CARE

• Understand why patients access health care in an urgent manner.
• Consider the difference in the Doctor-Patient relationship in the OOHs setting, as well as the differing challenges.
• Appreciate the potential clinical risk in unsupported settings, as well as the undifferentiated presentation of illness out of hours.
• How access to out of hours care has changed during the Covid-19 pandemic.

PALLIATIVE CARE 

• Consider team working in End of Life Care.
• Identify examples of End of Life decision making.
• Explain common problems and solutions around pain control, drug choice, and drug administration including syringe drivers.
• Consider the role of Funeral Directors and support for bereaved families.
• Consider relevant details regarding rituals for death management, and legal aspects of Death Certification and cremation.

LEARNING AND TEACHING 3

·       Continuously evaluating and improving the care provided

·       Adopting a safe and scientific approach to improve quality of care

·       Knowing limits and asking for help

·       Supporting the education and development of colleagues

LEADERSHIP AND TEAMWORK 3

·       Understand the role of each member of the Primary Care Team in the care of patients and their families.

·       Consider the skills and responsibilities of individual team members, both within the Surgery and with continuing care at home.

·       Working as an effective team member

·       Coordinating a team-based approach to the care of patients

·       Applying leadership skills to improve your organisation’s performance

3.  RCGP 2010 “THE CORE CURRICULUM STATEMENT: Being a General Practitioner”, p11

II) SKILLS

During the GP attachment you will have a chance to observe and learn from experienced Clinicians, and consider how they practice the science and art of medicine in a Primary Care context. 

You will also have the opportunity to develop yout own skills both in clinical areas, and in communication with patients and colleagues.

CLINICAL PROCEDURES

You should refer to the Year 5 Practical Procedures and Clinical Skills Logbook which includes many of the following common techniques. A number of these are listed below; 

• Examining the Eyes including fundoscopy
• Examining the Ears, Nose, and Throat including syringing ears
• Measuring the Blood Pressure
• Testing Urine - dipstick and pregnancy tests 
• Measuring Blood Glucose on a meter
• Performing a Vaginal examination and taking a Smear Test
• Examining the Breasts
• Performing a Rectal examination
• Performing Intramuscular, Intra-dermal, and Subcutaneous injections
• Examining the Musculoskeletal system - including the back, knees, and shoulder joints
• Examining a child

You will need to manage their own risk with agreement with their GP tutors in taking part in these procedures and should wear appropriate PPE, in the light of the Covid-19 pandemic.

COMMUNICATION SKILLS

Skills and techniques should include some of the following; 

• Develop communication skills in remote consulting, both telephone and video consultations
• Explaining how to use devices for the treatment of Asthma
• Advising and instructing on the use of Contraceptives
• Taking an Alcohol and Smoking history
• Communication between Doctors and other Health Professionals regarding Patient Care
• Communication across the Primary and Secondary Care interface
• Discussion of follow up management with Doctors, Patients, and Carers
• Discussion of risk potential and expressing perceptions of risk

PRESCRIBING 

• Illustrate the requirements for Prescribing in General Practice
• Demonstrate the importance of, and problems with patient adherence to therapy
• Identify the clinical risks associated with poly-pharmacy and drug interactions
• Identify the role of Community Pharmacists in patient care including, medicine usage and understanding, concordance, dispensing rules, and regulations including Controlled Drugs

III) ATTITUDES

ETHICS

Fitness to practise

·       Demonstrating the attitudes and behaviours expected of a good doctor

·       Managing the factors that influence performance

Maintaining an ethical approach

·       Treating others fairly and with respect and acting without discrimination

·       Providing care with compassion and kindness

Communication and consultation

·       Establishing an effective partnership with patients

·       Maintaining a continuing relationship with patients, carers and families

Maintaining a Holistic Approach

• Understand the effect of illness on the community.
• Demonstrate the importance of the family as well as the cultural, socio-economic, and psychological background on the management of patients and how they present in General Practice.
• Engage in the care of patients within the Practice.
• Appreciate that uncertainty exists in Primary Care, and consider how to minimise the risk to Patients, Carers, and the Doctor.
  

THE DOCTOR-PATIENT RELATIONSHIP 

• Demonstrate Professional Behaviour when undertaking independent tasks.
• Value and practise good Communication Skills.
• Analyse the nature of the Doctor-Patient relationship, and how this relationship is used whilst interacting with patients.
• Appreciate how the Doctor's own views, feelings, and life experiences can influence patient care, and consider how this should be managed.
• Demonstrate the importance of making decisions in Partnership with colleagues and patients.

TEACHING AND LEARNING ACTIVITIES

CENTRAL TEACHING & CORE CASES: ON-LINE

First (Intro Day) and Last (Closing Day) days of the block. The Introductory morning includes an orientation to GP placements in the new environment.

Closing day includes an ethics lecture and discussion of ethical cases on the placement as well as a formative Mock OSCE in clinical and communication skills relevant to Primary Care. You will be expected to complete the managing risk on clinical placement module prior to starting the GP placements.

Core Cases: on-line fortnightly (NEW) – You  are required to work though and complete clinical scenarios (including catching up on Year 4 work) and applied ethics for Year 5. You will do the cases in self directed time and be supported virtually by central GP tutor for a case discussion every two weeks. 

STUDENT SURGERIES

During this placement you are required to see and assess patients independently and then discuss the management and prescribing needs with your GP tutor. This should include regular sessions to see ‘your own’ patients. The supervising GP should always make their own assessment of the patient and will need to prescribe any medication required. This experience represents independent practice in a safe setting. In the new environment, your consultations will largely be by telephone or video.

Where possible, we would request that your have opportunity to do face to face examination as much as possible in preparation for when you become Foundation doctors.

On occasion students may work in pairs. When this happens, one should consult whilst the other observes, takes notes, and gives feedback to their colleague at the end. This supports independent practice and the development of skills in giving professional feedback.

SELF-DIRECTED LEARNING

You are expected to learn independently as part of your time in Primary Care, and will undertake a shared project during the placement. It is appropriate for you to use self-directed study time for both the completion of assessed work, and to follow up learning from patient contact.

SMALL GROUP TUTORIALS

Tutors should arrange at least one Tutorial a week for the group of students at the Practice. These should cover the breadth of Primary Care learning, and consider your learning needs. There are specific placement objectives which may provide a useful guide. 

ASSITANTSHIP & PROFESSIONAL SHADOWING

This is a GP Assistantship and we would encourage you to be involved in chronic disease management as much as possible and also develop experience of e-consulting in this area.

‘Sitting in’ is not the main aspect of this placement, some time can be spent ‘sitting in’ with or shadowing members of the Primary Care Team. Particularly relevant experiences include District Nursing, Community Pharmacists, Palliative Care Specialist Nurses, and Practice Nurse Clinics specialising in Chronic Disease management. 

Where possible this should involve active particpntion and includes reflection and summarising what you have learnt.

HALF DAY VIRTUAL MORNING IN PALLIATIVE CARE

This session has been arranged by St Joseph’s Hospice, Mare Street, London E8 4SA. 

It consists of a virtual half-day session facilitated by Palliative Care Specialists, and you will be informed of the date.  

All students including those on self-organised GP placements will be expected to attend this session.

OUT OF HOURS Care

We are not arranging an out of hours session for students on this GP placement. We are asking you to complete written work on the interface between Primary and Secondary Care and the lived experience of patients trying to access care out of hours.

You should consider how risk is managed by Clinicians seeing patients without access to notes, without continuity of care, and without the tests available in A&E. You should complete a coordinate my care plan.

PRACTICE BASED PROJECT

You will be expected to work in pairs during their placement on a short Practice Based Project (those students placed individually in a Practice should work on their own). The subject and type of project can vary but should be related to an area of Primary Care where a team approach to care is needed. We would encourage you to focus on aspects of leadership or teaching within the practice.

A topic for the project should be agreed with the GP Tutor, and you are encouraged to develop your own ideas, whilst considering the needs of the Practice. There is no set type of project, and options include a quality improvement project, audit, a patient survey, a leaflet, or a poster. The GP Tutor will assess and grade the project at the end of the placement. You should be given the opportunity to present their project to the practice team.

We hope that the project will provide an opportunity for you to learn, as well as allowing the Practice to positively impact patient care. The practice project can also be submitted for the North East London Faculty RCGP prize.

PATIENT CASE AND REFLECTION ON PROFESSIONAL PRACTICE PRINCIPLES

This task consists of a reflective case write-up followed by a discussion between you and Tutor about the issues raised. Both aspects of the task are important, and contribute towards the assessment. The write-up should be now more than 1000 words long, including a short case summary of no more than 300 words.

The patient chosen should have complex needs such as Palliative Care, or a high risk of admission. You must show reflection on two of the GMCs "Duties of a Good Doctor" criteria. 

At least one of these principles should be either "Relationship with Patients" or "Working with colleagues". Once the cases have been marked Tutors should arrange for the learning outcomes to be shared and discussed in a group session, to encourage peer review and learning. 

COMPLEX CARE PLAN

The aim of this task is to develop skills in gathering relevant clinical information about a patient with chronic conditions and needs, summarising this information, and communicating the management plan to colleagues in an appropriate written manner. This is particularly important in the Primary Care setting where chronic issues present often.

You should spend time interviewing and examining a patient, whilst reviewing the medical record. The patient selected should have chronic and complex needs, more than one chronic condition, and be taking multiple regular medications. The patient may be seen on a virtual home visit.

The task provides you with an opportunity to assess a case in further detail, review a patient in their own setting, and consider how you can share and communicate your plan effectively with colleagues.  

The Care Plan should be written for colleagues, using the template available on QMPlus. 

For students on two shorter placements see details under Assessment

ASSESSMENT

There will be COMPULSORY ASSESSMENTS throughout the placement, and grades will be assigned by the GP Tutor after consultation with others in the Practice who have been involved in teaching.

A full summary of all assessments required for this placement is shown below;

Mini-Clinical Evaluation Exercise (Mini-CEX) - Two of these are required for each student during the placement. One should take place during Week 1, and the second should take place before Week 8.

• Patient Feedback Forms – 10 patient feedback forms to be completed. This should be completed by week 5 and feedback should be reviewed by the GP tutor. This can be included as part of the midway assessment. The patient feedback forms will be available on QM+.
• ‘Midway Assessment’ at Week 5. This is to include a review of 1 x MiniCEX and the returned Patient Feedback Forms (as above). This assessment can be used as a check point to review the og book and to discuss with the GP Tutor how the placement is going. If there are any concerns at this Midway Assessment they can be discussed with the Year 5 team.

·       Patient Case and Reflection on Professional Practice Principles - Please see activities above.

·       Practice Based Project in pairs - Please see activities above. 

·       Complex Care Plan - Please see activities above.

·       Significant Event Analysis – write up and discussion in SEA team meeting

·       Assessment of Professional Attitude and Conduct - Online Form to be submitted by the GP Tutor at the end of the Placement.

·       Overall Assessment of Performance - Online Form to be submitted by the GP Tutor at the end of the Placement.

The overall grades will range from Commended, Pass, and Referred. The latter should be awarded if attendance has been unsatisfactory without an appropriate reason, or if poor performance warrants it. 

Significant periods of absence will be notified to the Unit Convenor as soon and may lead to the student repeating the block and refused entry to Finals or Graduation.

STUDENTS RECEIVING A REFERRED GRADE:

Students who receive a referred grade will be asked to meet with the Unit Convenor for a further discussion.

STUDENTS ON SPLIT PLACEMENTS

If you have chosen to split your placement between two Practices your learning outcomes and activities are the same for you and the assessments are equivalent. Specific requirements for two three-week placements are shown below;

·       One Mini-CEX should be completed in each placement.

·       The Complex Care Plan should be completed during the first placement.

·       The Patient Case and Reflection on Professional Practice Principles should be completed during the second placement. 

·       The Practice Based Project should span both placements, and should focus on an aspect that compares the two Practices.

• Significant Event Analysis – write up and discussion in SEA team meeting during either placement.
• Patient feedback by the end of the second placement.

·       An Assessment of Professional Attitude and Conduct Form should be submitted by each Practice.

·       A separate Overall Assessment Form should be submitted by each Practice.

EVALUATION

Frequently Asked Questions

Where are the assessment forms?

These are under the assessment section on the GP Assistantship section of QMPlus here

Is the Patient Case and Reflection Task marked centrally like previous SSCs?

No. The Patient Case and Reflection Task is marked by the GP Tutor. A discussion between the Student and the Tutor about the Professional Principles outlined in the case also contributes to the overall grade. 

Are the Mini-CEXs marked?

Yes. They are marked by the GP Tutor however the marks are not uploaded onto the central online system. You are expected to complete two Mini-CEXs during the placement; one during Week 1, and one before Week 8 (or one Mini-CEX per placement if you are doing a split placement). 

Can I see patients on my own?

Yes, indeed this is expected. You should be able to see and manage a lot of the problems that present in a safe and supervised manner. You should always check the management with your supervising GP before the patient leaves. The GP Tutor remains clinically responsible for the patient so will decide how independently you can work safely. You are not able to legally issue prescriptions but can either write 'shadow' prescriptions, or prepare a prescription for a qualified doctor to sign. 

Can I take time off for other activities?

Time off is subject to the normal College Policies. This includes attendance at Academic Conferences, religious requirements, and other special leave requests. These policies are available from QMPlus and the Student Office. CBME will inform GP Tutors about the few exceptional days that you may have to miss due to central exams (e.g. SJT, PSA).

Who should I inform when unwell?

In no circumstances should you attend if unwell, and if they you symptoms of COVID-19 you must arrange a test and isolate according to the guidance current at the time. Please see the Student Learning Agreement for more information.

Make sure you know how to contact key people at your Practice out of normal opening hours if needed. Either ask for the mobile numbers for your GP tutor or the Practice Manager, or the 'bypass' number for the Practice. If you are ill you are expected you are expected to inform the practice ASAP and keep them informed of how long  you are likely to be away. You will also need to follow the usual process of keeping the Student Office informed through Tom Schindler at t.schindler@qmul.ac.uk.

Should you sustain a needle stick injury whilst on placement in the Community, you are advised to access emergency treatment via local services. If there are no clear guidelines then you should attend your nearest A&E as soon as possible for assessment and treatment. Please also contact the CBME Admin Team urgently, who will direct you to Occupational Medicine at Mile End for follow up.

Where are the plenary days held? Is there a time table?

The 'Intro Day' and the 'Closing Day' will be held virtually, online. You will be sent links on QM Plus so that you are able to attend these. Timetables for these days are shared on QMPlus. 

The virtual 'Intro Day' will provide an orientation to GP placements run by Dr Cooke and Dr Sood and should finish by 4pm.

The 'Closing Day' begins with an Ethics Lecture at 10am, followed by workshops and a Mock OSCE in the afternoon. The day usually ends by 4.30pm. 

What are the details for the Online Core Cases?

You will complete 4 clinical scenarios every two weeks over the 9-week placement in order to catch up on specialties missed in Year 4 and with applied ethics and professionalism from Year 5. Every two weeks you will have a virtual group tutorial with your central GP tutor to discuss the issues around the case. There will also be a discussion forum for the tutorial group where you can post comments which will be facilitated by the central GP tutor.