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Are family practice trainers and their host practices any better? comparing practice trainers and non-trainers and their practices

Are family practice trainers and their host practices any better? comparing practice trainers and... Background: Family Physician (FP) trainees are expected to be provided with high quality training in well organized practice settings. This study examines differences between FP trainers and non-trainers and their practices to see whether there are differences in trainers and non-trainers and in how their practices are organized and their services are delivered. Method: 203 practices (88 non-training and 115 training) with 512 FPs (335 non-trainers and 177 trainers) were assessed using the “Visit Instrument Practice organization (VIP)” on 369 items (142 FP-level; 227 Practice level). Analyses (ANOVA, ANCOVA) were conducted for each level by calculating differences between FP trainees and non- trainees and their host practices. Results: Trainers scored higher on all but one of the items, and significantly higher on 47 items, of which 13 remained significant after correcting for covariates. Training practices scored higher on all items and significantly higher on 61 items, of which 23 remained significant after correcting for covariates. Trainers (and training practices) provided more diagnostic and therapeutic services, made better use of team skills and scored higher on practice organization, chronic care services and quality management than non-training practices. Trainers reported more job satisfaction and commitment and less job stress than non-trainers. Discussion: There are positive differences between FP trainers and non-trainers in both the level and the quality of services provided by their host practices. Training institutions can use this information to promote the advantages of becoming a FP trainer and training practice as well as to improve the quality of training settings for FPs. Keywords: Primary care, Family practice, Quality of healthcare, Teaching, Workload Background delegation [1,3,4]. Many Colleges, such as the College of Family physician (FP) trainers and their host practices Family Physicians of Canada or the Royal College of are expected to be places of excellence in order to pro- General Practitioners in the UK, have a responsibility in vide a predetermined standard of medical education. setting the standards for the training, in certification and Some evidence for this hypothesis is already available, lifelong education of FPs. Vocational training has be- which shows differences between FP trainers and non- come compulsory in the European Union, requiring a trainers and their practices, although the data are mainly high-standard of training and methods to assess the from the 1990s [1-4]. Three of these studies found FP quality of the training [5,6]. FP training institutes are trainers to be better qualified than non-trainers for obliged to provide trainees with professional FP trainers some organizational competencies like equipment and working in excellent practice settings [7,8]. We need therefore information on the quality and added value of training practices and FP trainers [9]. Providing excel- * Correspondence: J.Braspenning@iq.umcn.nl lence in training requires more than the definition of IQ healthcare (114), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500, HB, Nijmegen, the Netherlands standards for FP trainers and their practices alone [10]. Full list of author information is available at the end of the article © 2013 van den Hombergh et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 2 of 8 http://www.biomedcentral.com/1471-2296/14/23 In the Netherlands FP trainers receive instruction and have been changed to adjust the instrument to the per- training to become a teacher and clinical supervisor, [8] manent changes in GP-care. and training practices are stimulated to participate in a The questionnaires focused on infrastructure (premises practice accreditation program providing detailed feed- and equipment, practice management), the team (delega- back to the FP and the practice (Appendix 1) [11-13]. tion to staff, cooperation with other care providers, service The feedback offers trainers, training practices, and and organization, administration, workload (hours per institutions detailed information that could help to show week), job stress (scales), information (record keeping, pa- where improvement in organization is needed [14]. tient information) and quality management (CME, QI), Moreover, it makes explicit what the added value and see Table 1 and 2. All items were answered on a ‘yes’ or advantages are of being a trainer for both the training ‘no’ basis (except for workload and job stress that used practice and the FP. Likert scales). We also collected data on FP and the prac- The aim of this study was to explore differences in the tice characteristics, see Table 3. structure and process measures between FP trainers and non-trainers and their practices, to see whether there is Analyses added value in terms of the quality of services provided The differences between FP trainers and non-trainers to patients and in the quality of the practice organization were calculated for each of the 142 FP-level items with a of training practices as a host organization for trainees. one-way analysis of variance (ANOVA). Cohen’s d has been used to estimate effect sizes from the quantitative and dimensional measures. Because of the large number Methods of multiple comparisons involved, the effect sizes Setting and design (Cohen’s d ) were only calculated for the significant 335 FP non-trainers and 177 FP trainers voluntarily differences (p<0.05). Cohen suggested effect sizes in participated in the practice accreditation program in terms of: d=0.2 is small, 0.5 moderate and 0.8 large [16]. 2006–2007. A practice is denoted as a training practice When the covariates (gender, age, years of practice ex- when at least one FP trainer for postgraduate training is perience, weekly hours worked, and number of patients) employed in that practice; a training practice can have were significantly different for the two groups, an ana- therefore both FP trainers and non-trainers. There were lysis of covariance was used (ANCOVA). We considered 88 non-training practices (34.9% single-handed) with a the significant differences between the two groups only total of 164 FPs, and 115 training practices (16.5% for those items for which an effect size was calculated. single-handed) with a total of 348 FPs. Sixty-two We will present effect sizes only for those items that practices (30.5%) were practices with two FPs (32 non- differed significantly (p<0.05) after the covariate analysis. training and 30 training practices). Seventy-six practices The differences between the 227 practice level items for (37.4%) were group practices comprising 1 to 6 FP training and non-training practices were analyzed in the trainers, and 1 to 8 FP non-trainers. The practices were same way. The covariates to be corrected for were: type spread all over the Netherlands. All practices agreed on of practice (single handed, two FPs, more than two FPs, the use of the data at an aggregated level. Having this health care centre), practice location (next to FP’s house kind of informed consent a separate ethical approval is or not), urbanization level (small village, medium to not required under Dutch law. large town, medium size city, or large city), number of patients, weekly hours worked (fte) per 1,000 patients Instrument and procedure for the nurse, weekly hours worked (fte) per 1,000 The Visitation Instrument to assess Practice organization patients for management support, and the number of [11] (VIP) was used to collect the data, which contains years the FP has worked in the current practice. 369 items; 227 items at the practice level and 142 at the FP level. The VIP-tool includes all items of the Results international validated European Practice Assessment The characteristics of the participating FPs and practices indicators (EPA) [15]. It uses a combination of ques- are shown in Table 3. FP trainers were more often male, tionnaires that are completed by FPs and staff members, older, had more experience as a FP, worked longer hours, patient questionnaires and observational checklists and had more patients. FP training practices were more completed by trained independent observers. These often suburban practices with more partners, more trained observers collected and processes the data from patients, more assistance and more management sup- the questionnaires and the observation in the practice in port. The 177 FP trainers scored higher on all except a database for analysis. For a full description of the one (UV-lamp for eye diagnostics) of the 142 FP-level method and the process of data collection we refer to a items and significantly higher on 47 of the 142 items previous publication [11]. Over the years some items (Table 1). Training practices scored higher on all 227 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 3 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 1 Differences between FP trainers and non-trainers in organization of care, (FP-level, n=512) Main categories & subcategories N.of N.of Items that differed after Effect size items items covariate correction* Cohen’s d# I Infrastructure 1. Surface of waiting room & FP’s office 2 1 Premises Medical equipment 1. Medical equipment in the practice 17 5 2. Number of vials 3 3. Content of FP’s bag 19 3 4. Use of instruments/diagnostics 12 10 Hyfrecator .27 Electrocardiograph EKG .22 Sims-Hühner test .19 Audiometer .23 Doppler device .27 Peak flow meter .22 5. Applying technical skills 14 8 Examining fluor slide .19 Removing lipoma/ atheroma .23 6. Eye diagnostics 9 5 Lenses of −0.5 & +0.5 D .27 Stenopeic aperture .24 II Team Workload (hrs/wk) 1. Activities directly patient-related 3 2 Consultations, visits & calls .20 2. Activities indirectly patient-related 8 3 3. Quality Improvement (+ CME) 3 4. Other professional activities (meetings) 1 5. Total of 1–4 = time/ week in practice 4 6. Workload/ week (all activities) 5 2 7. Breaks 2 Job stress (5 scales) 1 1. Working with pleasure & commitment 4 (1) 1 Work w. pleasure & commitment .24 scale= 1 item 2. Being busy with irrelevant tasks 4 (1) 3. Satisfaction with available time for tasks 5 (1) 4. Satisfaction with investment on patients 3 (1) 1 5. Burnout at the end of the day 16 (1) III Information Record keeping Patient info 1. Quality of electronic medical records 4 2. Using FP Information System 11 2 1. Frequency of handing out patient info 1 2. Organizing patient information 10 1 IV Quality management Q Assessment 1. Assessing/testing medical skills 9 3 Video record of consultation 1.57 Total Total number of items 142 47 13 Δ Number of items that differed significantly between the two groups * Covariates: gender, age, years of experience, weekly hours worked, and number of patients. # Significant after covariate correction. practice level items and significantly higher on 61 of the FP level 227 items (Table 2). Most of the differences were found After correction for covariates, FP trainers reported in ‘medical equipment’. The differences between FP carrying out diagnostic activities more often than non- trainers and non-trainers that were significant after cor- trainers; such as audiometry, Doppler for detecting per- rection for covariates are described below in more detail ipheral arterial obstruction, EKG, spirometry, Sims for FP and practice level respectively. Hühner test for infertility and eye-diagnostics (using a van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 4 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 2 Differences between FP training & non-training practices in organization of care (practice level, n=203) Categories & subcategories Topics within subcategory N.of N.of Items that differed after Effect size items items covariate* correction Cohen’s d# I Infrastructure Premises 1. m [2] of waiting room and FP’s office 4 0 Medical equipment & Hygiene 2. Office equipment 10 3 1. Hygiene 11 2 2. Emergency care 13 3 EKG .33 3. Special instruments/equipment 13 6 Audiometer .47 Hyfrecator .32 4. Availability of lab tests 8 5 Peak flow meter .46 Digital Hb meter 35 ESR 35 Occult blood in faeces 35 Accessibility Services & organization 1. Waiting time for answering telephone 1 0 1. Organization of the practice 17 3 2. Preventive service of the practice 1 1 3. Preventive tasks provided by practice 11 2 II Team Delegated tasks 1. Medical-technical and diagnostic tasks 14 10 Nitrogen treatment .33 Compression therapy .53 Removing splinters .41 Vena puncture .42 Taping ankle sprain .31 Audiometry .40 Making EKGs .40 Collaboration with colleagues 2. Chronic diseases & prevention tasks 15 1 Spirometry .43 3. Organization and administration 9 1 1. Time meeting with staff 2 0 2. Time meeting with colleagues 2 0 3. Collaboration in the group practice 11 4 4. Time meeting other prim. care providers 6 2 5. Collaborating with prim. care providers 7 0 6. Collaborating with the hospital 4 1 7. Consultations of specialist/ consultants 10 2 8. Collaborating with other care providers 11 0 III Information Record keeping 1. Computerized Medical Records 9 0 Risk factors for CVD .33 2. Electronic communication 6 1 3. Use of separate prevention module 3 2 Patient info 1. Supplying patient info by practice 6 1 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 5 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 2 Differences between FP training & non-training practices in organization of care (practice level, n=203) (Continued) IV Quality management FP group Practice 1. Organization of quality in group practice 8 3 2. Quality policy within the practice 15 9 Calibration/maintenance .26 Patient survey 32 No commercial leaflets 34 Annual report 44 Tel. advice by staff using Dutch College guidelines 42 Policy for CME of staff 32 Appraisal for staff .23 Total Total number of items 227 61 23 Δ Number of items that differed significantly between the two groups *Covariates: type of practice, practice location, urbanization level, number of patients, fte nurse per 1,000 patients, fte management support per 1,000 patients, FP years working in current practice. # significant after covariate correction. stenopeic aperture, 0.5 D lenses for testing refraction covariates, except for the item “ (video) recording con- testing, UV-penlight, fundoscopy) and lab (KOH micro- sultation” d = 1.57). The differences at the practice level scopic examination of fluor vaginalis and fungi) ( Table 1). are somewhat larger than the FP level before and after They also reported carrying out more therapeutic activ- correcting for covariates. ities, such as minor surgery, etching epistaxis, use of the hyfrecator, applying pessaries and treatment of chalazion Discussion (Table 1). FP trainers spent more time directly with their Our findings show that FP trainers offer more services patients in the surgery and on the telephone and and work in better organized practices than non-trainers experienced more pleasure and commitment, more job , but the differences were small for FP trainers and satisfaction and less job stress than non-trainers. FP small-moderate for training practices. FP trainers trainers also reported more quality improvement activities, reported providing a wider range of services, including such as the video-recording of consultations. chronic care management, delegating more tasks and having better quality management. FP trainers enjoyed Practice level their job more, had more commitment, more job satis- After correction for covariates, training practices offered faction and less job stress than their non-trainer a significantly wider range of diagnostic and therapeutic counterparts, in spite of having more patients listed at services than non-training practices, such as audiometry, their practice and providing a wider range of services. hyfrecator, spirometry, EKG, Doppler and lab service Overall, our findings provide evidence of the benefits (ESR, urine sediment & culture, Haemoglobin). Diagnos- and improved outcomes of FP trainers and training tic tasks were more often delegated to the practice practices. The benchmarks set by the FP-trainers and nurse, such as spirometry and EKG as well as thera- training practices reported here could be used as the peutic tasks like Nitrogen application, compression ther- basis for Continuous Quality Improvement in the pro- apy for leg ulcer, removal sutures, and wound gluing and fession within both training and non-training practices. taping sprains. Training practices also scored higher on disease management for Diabetes and CVD (Table 2). Explanation and comparison with other studies The quality system of training practices was also well The results of our study are in line with the few previous developed, as there was a procedure for calibration and studies on some of the differences between FPs and maintenance of equipment as well as Dutch College of practices in training and non-training settings [1-4]. It GPs approved patient information, annual reports, ap- confirms that FP trainers and their practices are better praisal of staff, and policy for CME of staff and other equipped, offer more services and more quality assur- protocols for lab and treatment room. Overall, FP ance than non-trainers and their practices, and they trainers and their practices were better organized and offer more chronic disease programs and prevention. offer more services than non-trainers and non-training However, ours is the first study to examine such practices, although the differences are small (effect sizes differences in detail and across so many items of service are between .19 and .53 after correcting for the delivery/quality of care. Moreover, our findings show van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 6 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 3 Characteristics of family physicians and their practices FP characteristics Mean Non-trainers FP trainers Cohen’s d N = 512 & SD N = 335 N =177 * Gender Men 176 129 −0.42 Women 157 47 2 unknown 1 unknown Age M 44.05 49.95 0.77 SD 8.31 6.27 Years in practice M 12.94 19.42 0.75 9.13 7.70 SD 1 unknown 2 unknown Proportion of full-time FPs M 0.69 0.79 0.53 0.21 0.16 SD 1 unknown Total number of patients M 1,795.6 2,069.76 0.40 731.06 603.56 SD 12 unknown 1 unknown Practice characteristics Mean Non-trainer FP trainer Cohen’s d * N = 203 & SD practices practices N =88 N = 115 Type of practice M 2.62 3.08 0.29 1: single-handled SD 1.7 2: duo 3: group Practice location M 1.71 1.85 0.35 1: next to FP’s house SD 0.45 0.36 2: not next to FP’s house Urbanization level M 2.33 2.67 0.34 1: rural < 5000, 2: village 5 - SD 1.02 0.97 30.000, 3; small town 30–100.00, 4: large town > 100.000. Number of patients M 3,970.75 5,553.82 0.57 SD 2,530.87 2,969.41 Fte practice nurse per 1,000 patients M 0.41 0.44 0.68 SD 0.10 0.10 Fte management support /1,000 patients M 0.02 0.04 0.30 SD 0.03 0.11 Years worked in current practice M 12.09 14.14 0.33 SD 6.82 5.29 * A positive d means that the mean scores for FP trainers were higher than for non-trainers. that FP trainers report experiencing less job stress than presence of a trainee, while necessitating training related non-trainers, even though they report having more listed activities, relieves the trainers of some of their workload. patients to whom they offer more services (than non- trainers). A possible explanation is that FPs with less job Implications for education, policy and research stress are more interested in becoming a trainer or that Professionally each FP and even more so each trainer being a trainer has a stimulating and positive effect on needs to be informed about the quality of care of their morale and work satisfaction. It is quite likely that the practice. Having multiple sources of information helps van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 7 of 8 http://www.biomedcentral.com/1471-2296/14/23 facilitate comprehensive assessment, and a valid and ac- assessments within continuous quality systems such as ceptable accreditation visit method, as used in the Dutch ongoing accreditation, provide detailed feedback on national accreditation program, helps to provide reliable practice organization and care and highlights quality information, follow up over time and background data deficits that need to be addressed. There is a need for for all sorts of research. The FP training institutes in the multiple sources of data showing variation between FPs Netherlands are now asking all training practices to par- and practices that offers an extra opportunity for quality ticipate in the accreditation program and variation be- improvement for those undertaking the training of FP tween FP trainers on patient experiences and clinical trainees. performance can be studied using such data. It also fits into the concern of the FP training institutes to warrant Appendix 1. The Dutch FP accreditation program that trainees get the necessary diagnostic and thera- Since 2005, FPs had the opportunity to voluntarily par- peutic skills and see the right patient mix. Giving ticipate in the Dutch FP accreditation program. They re- trainers feedback on the gap in what can be learned in ceive information about the accreditation program their practice compared to other training practices including a questionnaire on expectations. Preparing for would benefit the quality of the training [17]. However, the first visit may take about one year. FP trainers and training practices also need to look be- FPs gather data about their practice management and yond accreditation to provide a high-standard of training patient care followed by a pre-audit of a trained obser- and use additional methods to assess the quality of the ver. Comparison with benchmarks of other FPs and training and its impact [13,14]. More comparisons be- practices helps to identify substandard performance tween training and non training practices and between stimulating FPs to make improvement plans. FP trainers and non-trainers need to be made across a The first audit is carried out after delivering these spectrum of other quality assessments such as pay-for plans to confirm adequate participation and to grant ac- -performance [18] or patient evaluations [19,20] or con- creditation. It is the start of a three-year accreditation tinuous professional development. program and an assessor does the follow-up of the plans. The prolongation of the accreditation depends on having Limitations met the objectives of the improvement plans. The sample included and compared FPs and practices The measurement in the accreditation program uses that were all equally motivated to participate in the previously validated instruments such as VIP [11], clin- Dutch practice accreditation program, reducing possible ical performance [12], and Europep [13]. The measures bias in comparing the two groups. The analyses included have been based on questionnaires for FPs and practice a large number of variables and almost half of the nurses, on structured observation by trained observers differences found were significant and a third of those and on patient questionnaires as well as on patient data remained significant after correction for covariates. from electronic medical records. However, the results show comprehensively that FP trainers and their practices are better organized than Competing interests non-trainers and their practices. Another limitation of The authors declare that they have no competing interests. the study was that we only looked at structure and processes, clinical patient outcomes were not included. Authors' contribution We hope to present these results, when data on the PvdH, SS-S, the main investigators analyzed the questionnaires and drafted this manuscript. JB, the project leader, was involved in all aspects of the treatment of chronic diseases become are available from study. AK, BB and SC participated in discussions about the reporting. All the Dutch FP accreditation program. authors read and approved the final version of the manuscript. Conclusion and future directions Acknowledgements Our findings show that FP trainers and their host This study was supported by SBOH, the employer of GP trainers in the practices offer a wider range of services with more team- Netherlands. work, more quality management, and the trainers report Author details experiencing less job stress than non-trainer FPs. More- IQ healthcare (114), Radboud University Nijmegen Medical Centre, PO Box over, hosting a FP trainer in a practice may have positive 9101, 6500, HB, Nijmegen, the Netherlands. Department of Psychology, Tilburg University, PO Box 901535000LE, Tilburg, the Netherlands. spin offs on and for other colleagues. All this may en- Department of Primary and Community Care (117), Radboud University courage more individual FPs and their host practice to Nijmegen Medical Centre, PO Box 91016500HB, Nijmegen, the Netherlands. become trainer and training practice respectively, as Health Sciences Research Group – Primary Care, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK. our study confirms that there are intrinsic benefits to FPs and practices to training status. However, for Received: 5 June 2012 Accepted: 14 February 2013 training and non-training settings alike, multiple quality Published: 21 February 2013 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 8 of 8 http://www.biomedcentral.com/1471-2296/14/23 References 1. Baker R: Comparison of standards in training and non-training practices. J R Coll Gen Pract 1985, 35:330–2. 2. Bates CM, Agass M, Tulloch AJ: General practice workload during normal working hours in training and non-training practices. Br J Gen Pract 1993, 43:413–6. 3. Baker R, Thompson J: Innovation in general practice: is the gap between training and non-training practices getting wider? Br J Gen Pract 1995, 45:297–300. 4. Elwyn G, Rhydderch M, Edwards A, Hutchings H, Marshall M, Myres P, Grol R: Assessing organisational development in primary medical care using a group based assessment: the Maturity MatrixTM. Qual Saf Health Care 2004, 13:287–94. 5. Godlee F: European countries need to work together. BMJ 2010, 341:c5395. 6. Sandars J: Continuing medical education across Europe. BMJ 2010, 341:c5214. 7. Prideax D, Alexander H, Bower A, Dacre J, Hasit S, Jolly B, Norcini J, Roberts T, Rothman A, Rowe R, Tallet S: Clinical teaching: maintaining an educational role for doctors in the new health care environment. Med Educ 2000, 34:820–6. 8. Boendermaker PM, Conradi MH, Schuling J, Meyboom-de Jong B, Zwierstra RP, Metz JC: Core characteristics of the competent general practice trainer, a Delphi study. Adv Health Sci Educ Theory Pract 2003, 8(2):111–6. 9. Kramer AW, Zuithoff P, Jansen JJ, Tan LH, Grol RP, van der Vleuten C: Growth of self-perceived clinical competence in postgraduate training for general practice and its relation to potentially influencing factors. Adv Health Sci Educ Theory Pract 2007, 12(2):135–145. 10. World Federation for Medical Education. Postgraduate Medical Education WFME Global Standards for Quality Improvement. WFME, Denmark, 2003. 11. van den Hombergh P, Grol R, Van den Bosch WJHM, van den Hoogen HJM: Assessment of management in General Practice: Validation of a practice visit method. Br J Gen Pract 1998, 48:1743–50. 12. Van Doorn A, Kirschner K, Bouma M, Burgers J, Braspenning J, Grol R: Evaluation of clinical performance measurement in Dutch accreditation program for general practice (in Dutch). Huisarts Wet 2010, 53(3):141–6. 13. Wensing M, Mainz J, Grol R: A standardised instrument for patient evaluations of general practice care in Europe. Eur J Gen Pract 2000, 6:82–7. 14. Overeem K, Faber M, Arah OA, Elwyn G, Lombarts KM, Wollersheim HC, Grol RP: Doctor performance assessment in daily practice: does it help doctors or not? A systematic review. Med Educ 2007, 41:1039–49. 15. Engels Y, Campbell S, Dautzenberg M, van den Hombergh P, Brinkmann H, Szécsényi J, Falcoff H, Seuntjens L, Kuenzi B, Grol R: Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005, 22:215–22. 16. Cohen J: Statistical Power Analysis for the Behavioral Sciences. 2nd edition. Hillsdale NJ: Lawrence Erlbaum; 1988. 17. de Jong J, Visser MRM, Mohrs J, Wieringa-de Waard M: Opening the black box: the patient mix of GP trainees. Br J Gen Pract 2011, 61(591):e650–e657. 18. Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M: Pay-for -Performance programs in family practices in the UK. N Engl J Med 2006, 27:375–84. 19. Vingerhoets E, Wensing M, Grol R: Feedback of patients’ evaluations of general practice care: a randomised trial. Qual Health Care 2001, 10:224–8. 20. Petek D, Künzi B, Kersnik J, Szecsenyi J, Wensing M: Patients' evaluations of European general practice–revisited after 11 years. Int J Qual Health Care 2011, 23(6):621–8. 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Are family practice trainers and their host practices any better? comparing practice trainers and non-trainers and their practices

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Family Physician (FP) trainees are expected to be provided with high quality training in well organized practice settings. This study examines differences between FP trainers and non-trainers and their practices to see whether there are differences in trainers and non-trainers and in how their practices are organized and their services are delivered. Method: 203 practices (88 non-training and 115 training) with 512 FPs (335 non-trainers and 177 trainers) were assessed using the “Visit Instrument Practice organization (VIP)” on 369 items (142 FP-level; 227 Practice level). Analyses (ANOVA, ANCOVA) were conducted for each level by calculating differences between FP trainees and non- trainees and their host practices. Results: Trainers scored higher on all but one of the items, and significantly higher on 47 items, of which 13 remained significant after correcting for covariates. Training practices scored higher on all items and significantly higher on 61 items, of which 23 remained significant after correcting for covariates. Trainers (and training practices) provided more diagnostic and therapeutic services, made better use of team skills and scored higher on practice organization, chronic care services and quality management than non-training practices. Trainers reported more job satisfaction and commitment and less job stress than non-trainers. Discussion: There are positive differences between FP trainers and non-trainers in both the level and the quality of services provided by their host practices. Training institutions can use this information to promote the advantages of becoming a FP trainer and training practice as well as to improve the quality of training settings for FPs. Keywords: Primary care, Family practice, Quality of healthcare, Teaching, Workload Background delegation [1,3,4]. Many Colleges, such as the College of Family physician (FP) trainers and their host practices Family Physicians of Canada or the Royal College of are expected to be places of excellence in order to pro- General Practitioners in the UK, have a responsibility in vide a predetermined standard of medical education. setting the standards for the training, in certification and Some evidence for this hypothesis is already available, lifelong education of FPs. Vocational training has be- which shows differences between FP trainers and non- come compulsory in the European Union, requiring a trainers and their practices, although the data are mainly high-standard of training and methods to assess the from the 1990s [1-4]. Three of these studies found FP quality of the training [5,6]. FP training institutes are trainers to be better qualified than non-trainers for obliged to provide trainees with professional FP trainers some organizational competencies like equipment and working in excellent practice settings [7,8]. We need therefore information on the quality and added value of training practices and FP trainers [9]. Providing excel- * Correspondence: J.Braspenning@iq.umcn.nl lence in training requires more than the definition of IQ healthcare (114), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500, HB, Nijmegen, the Netherlands standards for FP trainers and their practices alone [10]. Full list of author information is available at the end of the article © 2013 van den Hombergh et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 2 of 8 http://www.biomedcentral.com/1471-2296/14/23 In the Netherlands FP trainers receive instruction and have been changed to adjust the instrument to the per- training to become a teacher and clinical supervisor, [8] manent changes in GP-care. and training practices are stimulated to participate in a The questionnaires focused on infrastructure (premises practice accreditation program providing detailed feed- and equipment, practice management), the team (delega- back to the FP and the practice (Appendix 1) [11-13]. tion to staff, cooperation with other care providers, service The feedback offers trainers, training practices, and and organization, administration, workload (hours per institutions detailed information that could help to show week), job stress (scales), information (record keeping, pa- where improvement in organization is needed [14]. tient information) and quality management (CME, QI), Moreover, it makes explicit what the added value and see Table 1 and 2. All items were answered on a ‘yes’ or advantages are of being a trainer for both the training ‘no’ basis (except for workload and job stress that used practice and the FP. Likert scales). We also collected data on FP and the prac- The aim of this study was to explore differences in the tice characteristics, see Table 3. structure and process measures between FP trainers and non-trainers and their practices, to see whether there is Analyses added value in terms of the quality of services provided The differences between FP trainers and non-trainers to patients and in the quality of the practice organization were calculated for each of the 142 FP-level items with a of training practices as a host organization for trainees. one-way analysis of variance (ANOVA). Cohen’s d has been used to estimate effect sizes from the quantitative and dimensional measures. Because of the large number Methods of multiple comparisons involved, the effect sizes Setting and design (Cohen’s d ) were only calculated for the significant 335 FP non-trainers and 177 FP trainers voluntarily differences (p<0.05). Cohen suggested effect sizes in participated in the practice accreditation program in terms of: d=0.2 is small, 0.5 moderate and 0.8 large [16]. 2006–2007. A practice is denoted as a training practice When the covariates (gender, age, years of practice ex- when at least one FP trainer for postgraduate training is perience, weekly hours worked, and number of patients) employed in that practice; a training practice can have were significantly different for the two groups, an ana- therefore both FP trainers and non-trainers. There were lysis of covariance was used (ANCOVA). We considered 88 non-training practices (34.9% single-handed) with a the significant differences between the two groups only total of 164 FPs, and 115 training practices (16.5% for those items for which an effect size was calculated. single-handed) with a total of 348 FPs. Sixty-two We will present effect sizes only for those items that practices (30.5%) were practices with two FPs (32 non- differed significantly (p<0.05) after the covariate analysis. training and 30 training practices). Seventy-six practices The differences between the 227 practice level items for (37.4%) were group practices comprising 1 to 6 FP training and non-training practices were analyzed in the trainers, and 1 to 8 FP non-trainers. The practices were same way. The covariates to be corrected for were: type spread all over the Netherlands. All practices agreed on of practice (single handed, two FPs, more than two FPs, the use of the data at an aggregated level. Having this health care centre), practice location (next to FP’s house kind of informed consent a separate ethical approval is or not), urbanization level (small village, medium to not required under Dutch law. large town, medium size city, or large city), number of patients, weekly hours worked (fte) per 1,000 patients Instrument and procedure for the nurse, weekly hours worked (fte) per 1,000 The Visitation Instrument to assess Practice organization patients for management support, and the number of [11] (VIP) was used to collect the data, which contains years the FP has worked in the current practice. 369 items; 227 items at the practice level and 142 at the FP level. The VIP-tool includes all items of the Results international validated European Practice Assessment The characteristics of the participating FPs and practices indicators (EPA) [15]. It uses a combination of ques- are shown in Table 3. FP trainers were more often male, tionnaires that are completed by FPs and staff members, older, had more experience as a FP, worked longer hours, patient questionnaires and observational checklists and had more patients. FP training practices were more completed by trained independent observers. These often suburban practices with more partners, more trained observers collected and processes the data from patients, more assistance and more management sup- the questionnaires and the observation in the practice in port. The 177 FP trainers scored higher on all except a database for analysis. For a full description of the one (UV-lamp for eye diagnostics) of the 142 FP-level method and the process of data collection we refer to a items and significantly higher on 47 of the 142 items previous publication [11]. Over the years some items (Table 1). Training practices scored higher on all 227 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 3 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 1 Differences between FP trainers and non-trainers in organization of care, (FP-level, n=512) Main categories & subcategories N.of N.of Items that differed after Effect size items items covariate correction* Cohen’s d# I Infrastructure 1. Surface of waiting room & FP’s office 2 1 Premises Medical equipment 1. Medical equipment in the practice 17 5 2. Number of vials 3 3. Content of FP’s bag 19 3 4. Use of instruments/diagnostics 12 10 Hyfrecator .27 Electrocardiograph EKG .22 Sims-Hühner test .19 Audiometer .23 Doppler device .27 Peak flow meter .22 5. Applying technical skills 14 8 Examining fluor slide .19 Removing lipoma/ atheroma .23 6. Eye diagnostics 9 5 Lenses of −0.5 & +0.5 D .27 Stenopeic aperture .24 II Team Workload (hrs/wk) 1. Activities directly patient-related 3 2 Consultations, visits & calls .20 2. Activities indirectly patient-related 8 3 3. Quality Improvement (+ CME) 3 4. Other professional activities (meetings) 1 5. Total of 1–4 = time/ week in practice 4 6. Workload/ week (all activities) 5 2 7. Breaks 2 Job stress (5 scales) 1 1. Working with pleasure & commitment 4 (1) 1 Work w. pleasure & commitment .24 scale= 1 item 2. Being busy with irrelevant tasks 4 (1) 3. Satisfaction with available time for tasks 5 (1) 4. Satisfaction with investment on patients 3 (1) 1 5. Burnout at the end of the day 16 (1) III Information Record keeping Patient info 1. Quality of electronic medical records 4 2. Using FP Information System 11 2 1. Frequency of handing out patient info 1 2. Organizing patient information 10 1 IV Quality management Q Assessment 1. Assessing/testing medical skills 9 3 Video record of consultation 1.57 Total Total number of items 142 47 13 Δ Number of items that differed significantly between the two groups * Covariates: gender, age, years of experience, weekly hours worked, and number of patients. # Significant after covariate correction. practice level items and significantly higher on 61 of the FP level 227 items (Table 2). Most of the differences were found After correction for covariates, FP trainers reported in ‘medical equipment’. The differences between FP carrying out diagnostic activities more often than non- trainers and non-trainers that were significant after cor- trainers; such as audiometry, Doppler for detecting per- rection for covariates are described below in more detail ipheral arterial obstruction, EKG, spirometry, Sims for FP and practice level respectively. Hühner test for infertility and eye-diagnostics (using a van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 4 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 2 Differences between FP training & non-training practices in organization of care (practice level, n=203) Categories & subcategories Topics within subcategory N.of N.of Items that differed after Effect size items items covariate* correction Cohen’s d# I Infrastructure Premises 1. m [2] of waiting room and FP’s office 4 0 Medical equipment & Hygiene 2. Office equipment 10 3 1. Hygiene 11 2 2. Emergency care 13 3 EKG .33 3. Special instruments/equipment 13 6 Audiometer .47 Hyfrecator .32 4. Availability of lab tests 8 5 Peak flow meter .46 Digital Hb meter 35 ESR 35 Occult blood in faeces 35 Accessibility Services & organization 1. Waiting time for answering telephone 1 0 1. Organization of the practice 17 3 2. Preventive service of the practice 1 1 3. Preventive tasks provided by practice 11 2 II Team Delegated tasks 1. Medical-technical and diagnostic tasks 14 10 Nitrogen treatment .33 Compression therapy .53 Removing splinters .41 Vena puncture .42 Taping ankle sprain .31 Audiometry .40 Making EKGs .40 Collaboration with colleagues 2. Chronic diseases & prevention tasks 15 1 Spirometry .43 3. Organization and administration 9 1 1. Time meeting with staff 2 0 2. Time meeting with colleagues 2 0 3. Collaboration in the group practice 11 4 4. Time meeting other prim. care providers 6 2 5. Collaborating with prim. care providers 7 0 6. Collaborating with the hospital 4 1 7. Consultations of specialist/ consultants 10 2 8. Collaborating with other care providers 11 0 III Information Record keeping 1. Computerized Medical Records 9 0 Risk factors for CVD .33 2. Electronic communication 6 1 3. Use of separate prevention module 3 2 Patient info 1. Supplying patient info by practice 6 1 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 5 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 2 Differences between FP training & non-training practices in organization of care (practice level, n=203) (Continued) IV Quality management FP group Practice 1. Organization of quality in group practice 8 3 2. Quality policy within the practice 15 9 Calibration/maintenance .26 Patient survey 32 No commercial leaflets 34 Annual report 44 Tel. advice by staff using Dutch College guidelines 42 Policy for CME of staff 32 Appraisal for staff .23 Total Total number of items 227 61 23 Δ Number of items that differed significantly between the two groups *Covariates: type of practice, practice location, urbanization level, number of patients, fte nurse per 1,000 patients, fte management support per 1,000 patients, FP years working in current practice. # significant after covariate correction. stenopeic aperture, 0.5 D lenses for testing refraction covariates, except for the item “ (video) recording con- testing, UV-penlight, fundoscopy) and lab (KOH micro- sultation” d = 1.57). The differences at the practice level scopic examination of fluor vaginalis and fungi) ( Table 1). are somewhat larger than the FP level before and after They also reported carrying out more therapeutic activ- correcting for covariates. ities, such as minor surgery, etching epistaxis, use of the hyfrecator, applying pessaries and treatment of chalazion Discussion (Table 1). FP trainers spent more time directly with their Our findings show that FP trainers offer more services patients in the surgery and on the telephone and and work in better organized practices than non-trainers experienced more pleasure and commitment, more job , but the differences were small for FP trainers and satisfaction and less job stress than non-trainers. FP small-moderate for training practices. FP trainers trainers also reported more quality improvement activities, reported providing a wider range of services, including such as the video-recording of consultations. chronic care management, delegating more tasks and having better quality management. FP trainers enjoyed Practice level their job more, had more commitment, more job satis- After correction for covariates, training practices offered faction and less job stress than their non-trainer a significantly wider range of diagnostic and therapeutic counterparts, in spite of having more patients listed at services than non-training practices, such as audiometry, their practice and providing a wider range of services. hyfrecator, spirometry, EKG, Doppler and lab service Overall, our findings provide evidence of the benefits (ESR, urine sediment & culture, Haemoglobin). Diagnos- and improved outcomes of FP trainers and training tic tasks were more often delegated to the practice practices. The benchmarks set by the FP-trainers and nurse, such as spirometry and EKG as well as thera- training practices reported here could be used as the peutic tasks like Nitrogen application, compression ther- basis for Continuous Quality Improvement in the pro- apy for leg ulcer, removal sutures, and wound gluing and fession within both training and non-training practices. taping sprains. Training practices also scored higher on disease management for Diabetes and CVD (Table 2). Explanation and comparison with other studies The quality system of training practices was also well The results of our study are in line with the few previous developed, as there was a procedure for calibration and studies on some of the differences between FPs and maintenance of equipment as well as Dutch College of practices in training and non-training settings [1-4]. It GPs approved patient information, annual reports, ap- confirms that FP trainers and their practices are better praisal of staff, and policy for CME of staff and other equipped, offer more services and more quality assur- protocols for lab and treatment room. Overall, FP ance than non-trainers and their practices, and they trainers and their practices were better organized and offer more chronic disease programs and prevention. offer more services than non-trainers and non-training However, ours is the first study to examine such practices, although the differences are small (effect sizes differences in detail and across so many items of service are between .19 and .53 after correcting for the delivery/quality of care. Moreover, our findings show van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 6 of 8 http://www.biomedcentral.com/1471-2296/14/23 Table 3 Characteristics of family physicians and their practices FP characteristics Mean Non-trainers FP trainers Cohen’s d N = 512 & SD N = 335 N =177 * Gender Men 176 129 −0.42 Women 157 47 2 unknown 1 unknown Age M 44.05 49.95 0.77 SD 8.31 6.27 Years in practice M 12.94 19.42 0.75 9.13 7.70 SD 1 unknown 2 unknown Proportion of full-time FPs M 0.69 0.79 0.53 0.21 0.16 SD 1 unknown Total number of patients M 1,795.6 2,069.76 0.40 731.06 603.56 SD 12 unknown 1 unknown Practice characteristics Mean Non-trainer FP trainer Cohen’s d * N = 203 & SD practices practices N =88 N = 115 Type of practice M 2.62 3.08 0.29 1: single-handled SD 1.7 2: duo 3: group Practice location M 1.71 1.85 0.35 1: next to FP’s house SD 0.45 0.36 2: not next to FP’s house Urbanization level M 2.33 2.67 0.34 1: rural < 5000, 2: village 5 - SD 1.02 0.97 30.000, 3; small town 30–100.00, 4: large town > 100.000. Number of patients M 3,970.75 5,553.82 0.57 SD 2,530.87 2,969.41 Fte practice nurse per 1,000 patients M 0.41 0.44 0.68 SD 0.10 0.10 Fte management support /1,000 patients M 0.02 0.04 0.30 SD 0.03 0.11 Years worked in current practice M 12.09 14.14 0.33 SD 6.82 5.29 * A positive d means that the mean scores for FP trainers were higher than for non-trainers. that FP trainers report experiencing less job stress than presence of a trainee, while necessitating training related non-trainers, even though they report having more listed activities, relieves the trainers of some of their workload. patients to whom they offer more services (than non- trainers). A possible explanation is that FPs with less job Implications for education, policy and research stress are more interested in becoming a trainer or that Professionally each FP and even more so each trainer being a trainer has a stimulating and positive effect on needs to be informed about the quality of care of their morale and work satisfaction. It is quite likely that the practice. Having multiple sources of information helps van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 7 of 8 http://www.biomedcentral.com/1471-2296/14/23 facilitate comprehensive assessment, and a valid and ac- assessments within continuous quality systems such as ceptable accreditation visit method, as used in the Dutch ongoing accreditation, provide detailed feedback on national accreditation program, helps to provide reliable practice organization and care and highlights quality information, follow up over time and background data deficits that need to be addressed. There is a need for for all sorts of research. The FP training institutes in the multiple sources of data showing variation between FPs Netherlands are now asking all training practices to par- and practices that offers an extra opportunity for quality ticipate in the accreditation program and variation be- improvement for those undertaking the training of FP tween FP trainers on patient experiences and clinical trainees. performance can be studied using such data. It also fits into the concern of the FP training institutes to warrant Appendix 1. The Dutch FP accreditation program that trainees get the necessary diagnostic and thera- Since 2005, FPs had the opportunity to voluntarily par- peutic skills and see the right patient mix. Giving ticipate in the Dutch FP accreditation program. They re- trainers feedback on the gap in what can be learned in ceive information about the accreditation program their practice compared to other training practices including a questionnaire on expectations. Preparing for would benefit the quality of the training [17]. However, the first visit may take about one year. FP trainers and training practices also need to look be- FPs gather data about their practice management and yond accreditation to provide a high-standard of training patient care followed by a pre-audit of a trained obser- and use additional methods to assess the quality of the ver. Comparison with benchmarks of other FPs and training and its impact [13,14]. More comparisons be- practices helps to identify substandard performance tween training and non training practices and between stimulating FPs to make improvement plans. FP trainers and non-trainers need to be made across a The first audit is carried out after delivering these spectrum of other quality assessments such as pay-for plans to confirm adequate participation and to grant ac- -performance [18] or patient evaluations [19,20] or con- creditation. It is the start of a three-year accreditation tinuous professional development. program and an assessor does the follow-up of the plans. The prolongation of the accreditation depends on having Limitations met the objectives of the improvement plans. The sample included and compared FPs and practices The measurement in the accreditation program uses that were all equally motivated to participate in the previously validated instruments such as VIP [11], clin- Dutch practice accreditation program, reducing possible ical performance [12], and Europep [13]. The measures bias in comparing the two groups. The analyses included have been based on questionnaires for FPs and practice a large number of variables and almost half of the nurses, on structured observation by trained observers differences found were significant and a third of those and on patient questionnaires as well as on patient data remained significant after correction for covariates. from electronic medical records. However, the results show comprehensively that FP trainers and their practices are better organized than Competing interests non-trainers and their practices. Another limitation of The authors declare that they have no competing interests. the study was that we only looked at structure and processes, clinical patient outcomes were not included. Authors' contribution We hope to present these results, when data on the PvdH, SS-S, the main investigators analyzed the questionnaires and drafted this manuscript. JB, the project leader, was involved in all aspects of the treatment of chronic diseases become are available from study. AK, BB and SC participated in discussions about the reporting. All the Dutch FP accreditation program. authors read and approved the final version of the manuscript. Conclusion and future directions Acknowledgements Our findings show that FP trainers and their host This study was supported by SBOH, the employer of GP trainers in the practices offer a wider range of services with more team- Netherlands. work, more quality management, and the trainers report Author details experiencing less job stress than non-trainer FPs. More- IQ healthcare (114), Radboud University Nijmegen Medical Centre, PO Box over, hosting a FP trainer in a practice may have positive 9101, 6500, HB, Nijmegen, the Netherlands. Department of Psychology, Tilburg University, PO Box 901535000LE, Tilburg, the Netherlands. spin offs on and for other colleagues. All this may en- Department of Primary and Community Care (117), Radboud University courage more individual FPs and their host practice to Nijmegen Medical Centre, PO Box 91016500HB, Nijmegen, the Netherlands. become trainer and training practice respectively, as Health Sciences Research Group – Primary Care, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK. our study confirms that there are intrinsic benefits to FPs and practices to training status. However, for Received: 5 June 2012 Accepted: 14 February 2013 training and non-training settings alike, multiple quality Published: 21 February 2013 van den Hombergh et al. BMC Family Practice 2013, 14:23 Page 8 of 8 http://www.biomedcentral.com/1471-2296/14/23 References 1. Baker R: Comparison of standards in training and non-training practices. J R Coll Gen Pract 1985, 35:330–2. 2. 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