Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes | BMC Medical Education

Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes | BMC Medical Education

Literature review

Eight articles were included in the review [36,37,38,39,40,41,42,43] (appendix 3). We identified four design principles for interventions to learn intraPC: Participatory design, work process involvement, personalised education and role models. Table 1 shows a short description of the design principles and the associated codes.

Table 1 Design Principles literature review

Group interviews

Subsequently we conducted three group interviews with a total of eighteen participants between August and October 2017 (Table 2). We identified three design principles for interventions to learn PSCC in postgraduate training programmes, the aim of our study. One principle related to the importance of interaction: engage in a learning dialogue. One to the content of this learning dialogue: facilitate that the dialogue concerns collaboration. And one to the importance of a supportive context of learning: create a workplace that facilitates to engage in a learning dialogue (Table 3).

Table 2 Participants and duration of group discussions

Design principle 1 Interaction: engage in a learning dialogue

One key principle for interventions to learn PSCC was to give GP- and MS trainees the chance to engage in a learning dialogue with each other to create mutual understanding. Interaction was indicated a key factor in learning collaboration. This interaction could be face-to-face but also digitally. Experiencing each other’s work context was emphasised as one of the strongest learning mechanisms, however several less time-consuming possibilities as observation, joint education or telephonic interaction were also seen as promising.

MST (interview 1): “It would be great for specialty trainees to deliver care in the primary care setting. Not only observing. The experience will be greater. The more emotion, the better. Because you are responsible, you have to make choices… … it would be great for healthcare issues that are both treated in primary and secondary care, like diabetes.”

MST (interview 3): “It would be valuable to visit a patient at home after I’ve done an operation and have discharged the patient. ……. to see what happens at home, what questions and incertanties the patient, GP and careteam at home experience. Things they (patients eds.) probably not mention at their outpatient clinic appointment”.

ED (interview 2): “That an MS and a GP visit the patient at home, together. Learning collaboration in the context of patient care. That would be very valuable, but also costs a lot of time. I can imagine that instead of a whole day observing, which would be great in my opinion, you could explain to each other how your work day is organised and what problems you face. I know, it is less powerfull than expiriencing, but easier to organise. And than with small steps……”.

Design principle 2 facilitate that the learning dialogue concerns collaboration

Participants agreed that in order to learn PSCC interventions should facilitate that the dialogue is about knowledge and skills needed for this collaboration. They named the following topics as important in the dialogue: (1) Each other’s roles, expertise and contexts (2) Discussing or making collaboration agreements, and (3) Reflection on the collaborative process. They mentioned that current contacts between primary and secondary care doctors mainly focus on medical content, which was often valuable, but could be made more valuable when the process of collaboration and each other’s roles would be explicitly addressed as well.

GPT (interview 3): “If we, GPT and MST, would see patients together, we could learn from each other. …… Every doctor finished two months of a GP internship but then you are not aware of your future specialty. So if you visit a GP during your specialty training and experience how the GP may struggle with a patient with chest pain while as trainee cardiology in the hospital you have your troponines and ECG………………….That way you can learn the considerations a GP makes when the GP refers a patient”.

ED (interview 2): “When you called the hospital after you sent in a patient for consultation, do you discuss the referral process and how the collaboration went?” GPT1 “sometimes, when I feel the person on the other side of the phone has time and it feels like a low threshold contact than I ask quickly, “what did you think of the referral and our deliberation?”’ ED “Does that happen often? GPT2: “I think that in practice most of the time we check: did I make the correct diagnosis”.

Design principle 3 create a workplace that facilitates engagement in a learning dialogue

In all group interviews the importance of the workplace came forward. It was mentioned that without support from and changes in the work context interventions with the aim to learn PSCC will not succeed. This means that in development and implementation of interventions the workplace should be taken into account as a variable that affects learning PSCC. We distinguished five subcategories.

Intervention emphasises the urge for PSCC and is based on daily practice

All participants felt that interventions should take place in or are based on daily practice. Participants emphasised that trainees learn most from situations they recognise in and from daily practice. Participants felt that the need to engage in PSCC is not felt by all colleagues, trainees and supervisors, involved in this collaboration. They felt it was important to feel this need in order to engage in a learning dialogue. Emphasising today’s patient’s expectations and the need for improved work efficiency in interventions and in daily practice could contribute to feeling this need to collaborate and learning this collaboration.

Moderator (interview 3): “We heard in previous group interviews that it is hard to learn and change when the workplace is not changing. What could help to change daily practice?” GP: “[.] the patient, I think. Today’s patients tell what they want and who they expect to do it. And if we notice this and listen to the patient, then we might realise we have to move in a different direction.”

MST (interview 3) “ to me, It is a cultural thing. In todays’specialty training we are focussed on becoming a higly specialised specialist. For a big part of our training we are not thinking about the role of the GP and the fact that the patient will consultate their GP with questions the next day. So early in training we need to be made aware that when we see a patient we are only a small part of their care trajectory and we are working to get the patient as quickly at home as possible. And when we realise that, you feel the need to make sure this can be made possible, and you feel the need to collaborate.”

Presence of role models

Participants felt that a collaborative culture in the workplace facilitates learning collaboration. Several participants stressed the importance of supervisors as role models, but mentioned at the same time that collaboration is often not recognised as an important quality of a doctor in practice. Participants described role models as people who give examples of exemplary PSCC which they can observe and who help creating a collaborative culture.

ED (interview 2): Role modelling. Role modelling. Show how it should be done. Everything in the training programme needs to be shown the right way….

MS (interview 1)…………. there are role models I think. They are not very visible. When you ask: who do I need to do research, you get a quick answer: you have to go to him or her. But when you ask about who should learn me how to be a good collaborator? In surgery they will feel it is a “soft question”….

Participants also mentioned that ambassadors, for example a trainee and a supervisor together, could play a part in creating a culture that facilitates PSCC.

MST (interview 2): “I think, that some sort of ambassador function, works well sometimes. You cannot really tell up front if it will work, or not, that depends on the resistance you get. But if you entitle it as an ambassador, thus that you are expected to carry out your task, then you can get actively involved in morning and evening reports, or other moments.

Hence, when implementing an intervention for learning PSCC attention should be given towards the presence of role models or ambassadors to increase the chance of success.

The workplace provides time to learn PSCC

Both primary and secondary care trainees experience a lack of time due to work pressure and other priorities as a barrier to engage in a learning dialogue. They feel a need for dedicated time to learn PSCC in daily practice. A strategy to overcome this barrier is reserving time to engage in PSCC in the daily work schedule, not only for trainees, but for supervisors as well.

MST (interview 1): “Time……. I think… So, if the training programme, would reserve, just a little bit but some dedicated time for it (visit a GP practice) than you show as a supervisor that you judge it (PSCC) as important.”

MS (interview 3) “digital consultation is a nice way of collaboration, I think. And when this is paid for then. so then you could have 10 consultations from GPs at the end of the day, but you do have two hours’ time for it”.

Participants mentioned that it could help to place interventions in existing primary-secondary care contacts like consultation, triage or internships of GPTs in the hospitals as opportunities to discuss collaboration.

MS (interview 2) …………………………… We need to look at the contacts between primary and secondary care that already exist, or interdisciplinary organised education. I think that is the way to go. GPT: I agree.

Formalise learning PSCC in curricula

Another way to reserve dedicated time for learning PSCC is to include and describe learning goals for this collaboration in the speciality training curricula. In the current post graduate curricula PSCC is not included explicitly, no learning objectives are attached to PSCC and no assessment of this collaboration happens in daily practice. For supervisors it would be easier to create this time, if it were an explicit part of the training programmes.

MS (interview 1) “It is about defining learning goals and make sure that this is judged as important enough to make it an obligatory part of the curricula. That’s it, then it will happen.”

MS (interview 3) “That is something we need to pay attention to in our medical specialty training programmes. That contact with and involvement of the GP during admission is part of good medical practice. And that you will be judged on that.”

Our participants felt that supervisors should obligate their trainees to attend and engage in interventions to learn collaboration otherwise only trainees who like the subject would attend.

GPT (interview 1): “So, I do not know how you guys feel about it, but I am not inclined to do it [ask for feedback eds.], when I do not have to do it.”

MST (interview 2): “I was just about to say that, because it might sound childish, but you know who will attend that intraprofessional education programme.” MST2: “It has to be obligatory.”

Create a safe learning environment

One of the conditions to engage in a learning dialogue is that the environment where trainees learn is a safe one. Participants describe this as an environment with colleagues and educators who actively invite to reflect on collaboration. Furthermore, trainees should experience no hierarchy between GPs and MSs. This was specifically named in relation to using the GP trainees internships in secondary care as opportunities to discuss PSCC. Participants felt it was hard for a GP trainee to focus on collaboration and give feedback on this collaboration without being actively invited to do so in the secondary care environment.

GPT (interview 2): It would be easier to give my viewpoint as a GP in training on PSCC when I would be actively invited to do so…. I would feel a high threshold to comment on PSCC in a new environment where everybody knows each other. But if they would ask me do to so… then…. ED:.so asking for feedback should have more attention? MST”: mutuality at least, the focus should no only be: we want to teach you something, but also what can we learn from you. We really want to know.

In general, participants mentioned that knowing their collaboration partner personally would lower the threshold to contact them and engage in a dialogue. However, the number of trainees is high, and almost every day people start or end their training, so it is impossible to know everyone personally. The threshold could be lowered, when involved institutions organise days that trainees come together, both formal and informal.

Updated literature search 2017–2023

We found five articles that met our inclusion criteria [44,45,46,47,48]. The preliminary design principles from our literature research were recognisable in more recent literature. However, in three articles ([44,45,46] an important reason for success of the interventions was meeting one-another. The importance of interaction was emphasized in previous articles (codes as face-to-face, interactive design, small team interventions) but not as explicitly mentioned as in these last articles. This is in line with the findings of our focus groups in which interaction is named as key for learning PSCC.

Table 3 Design principles for interventions to learn PSCC in postgraduate training programmes

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