What influences on their professional development do general practice trainees report from their hospital placements? A qualitative study
The clinical learning environment has been described as the foundation of postgraduate medical education , with the quality of the training environment correlating to the later quality of care provided by graduates . The challenges of providing such training in hospitals, in addition to the primacy of patient need and service provision, are well described . Uniquely for General Practice (GP) trainees, some of this training is in an environment that is not their final workplace, i.e. the hospital, which furthermore may have little understanding of the future professional life of the GP trainee . However, the hospital environment has been reported as providing a high prevalence of morbidity to assist GP trainees in learning, and to show future GPs what the hospital can provide in future care collaboration . This model of GP training is standard across Europe . The rise of competency-based medical education  emphasises the workplace as a learning environment . Earlier publications on the hospital training component for GP trainees have focused on what GP trainees could learn from individual hospital placements . While the hospital provides experience in the management of acute illness, technical practice, diagnostic procedures [5], in contrast, tolerating uncertainty, awareness of psychosocial factors and patient-centeredness are learnt well in the GP learning environment . In addition, professional identity formation is now viewed as an essential aspect of specialty training , which may be more challenging for GP trainees in the hospital environment where there is occasional denigration of GP or undermining of GP trainees by some hospital specialists . On the other hand, GP trainees have also reported good peer support in the hospital training and rated hospital paediatrics and emergency medicine as useful . This international qualitative project seeks the views of GP trainees of how their hospital experience contributes to their professional development as a GP. 

A multi-country qualitative study, utilising semi-structured interviews, was undertaken. The research group consisted of GP trainees and supervisors from Belgium, Ireland, Lithuania, and Slovenia. Ethical approval was granted (or waived) by the appropriate body in the four countries. Belgium; Antwerp University Hospital (20/46 606), Ireland; The Irish College of General Practitioners (ICGP_REC_2020_T15), Lithuania; Not required, Slovenia; Republic of Slovenia Medical Ethics Committee (0120-381/2020/11). Developing the topic guide Following a literature search, nominal group technique was conducted with international educators in a workshop delivered at the WONCA Europe Conference (Berlin 2020) . Results were used to develop the topic guide ( Supplementary Appendix 1) in English, then translated into Slovenian, Dutch and Lithuanian languages. Recruitment Study participants  were selected by purposeful samplng to seek a broad range of trainees of different age, gender, prior experience, and country of primary medical degree. Participation was invited through young doctor’s associations, national GP trainee databases, GP trainee social media groups, National Trainee Conferences, and Day Release teaching sites. GP trainees who had less than three months hospital experience were excluded. Data collection Nine researchers (GP trainees from Belgium, Ireland, Lithuania, and Slovenia, 1 male and 8 female) conducted the interviews, which were face-to-face or via Zoom ® . The interviews took place between January 2021 and May 2021 and were conducted in the language of GP training in that country. The interviews were recorded and transcribed (by hand or using Otter ® software). The transcripts were anonymised, stored according to European General Data Protection Regulation (GDPR) and imported into NVivo® software for analysis. Interviews continued until no further new information was forthcoming. Data analysis Thematic analysis, following a six-step process , was employed to identify themes and patterned meanings. Data familiarisation of the transcripts and line-by-line open coding of each transcript was conducted by two researchers in each country, supported by NVivo ® (version 12). Initial meetings in each country discussed and refined the codes. Each country’s codebook was translated into English. Meetings with the researchers from all the countries condensed the codes and identified key categories and themes. Findings were verified using reflective conversations, comparing and contrasting the codebooks, noting and revising the categories in the light of the research question over several meetings, in line with previously published analytic methods . Reflexivity statement Most researchers are career GPs (range of experience between 1-31 years). Some researchers had previously embarked on a career as a hospital specialist but had changed careers. One of the researchers is on a hospital medicine career. We remained aware that as a research group we may have had a vested interest in promotion of GP as a career and diminution of hospital medicine, and despite our best efforts to the contrary, our interpretation may be biased. 

Following a literature search, nominal group technique was conducted with international educators in a workshop delivered at the WONCA Europe Conference (Berlin 2020) . Results were used to develop the topic guide ( Supplementary Appendix 1) in English, then translated into Slovenian, Dutch and Lithuanian languages. 

Study participants  were selected by purposeful samplng to seek a broad range of trainees of different age, gender, prior experience, and country of primary medical degree. Participation was invited through young doctor’s associations, national GP trainee databases, GP trainee social media groups, National Trainee Conferences, and Day Release teaching sites. GP trainees who had less than three months hospital experience were excluded. 

Nine researchers (GP trainees from Belgium, Ireland, Lithuania, and Slovenia, 1 male and 8 female) conducted the interviews, which were face-to-face or via Zoom ® . The interviews took place between January 2021 and May 2021 and were conducted in the language of GP training in that country. The interviews were recorded and transcribed (by hand or using Otter ® software). The transcripts were anonymised, stored according to European General Data Protection Regulation (GDPR) and imported into NVivo® software for analysis. Interviews continued until no further new information was forthcoming. 

Thematic analysis, following a six-step process , was employed to identify themes and patterned meanings. Data familiarisation of the transcripts and line-by-line open coding of each transcript was conducted by two researchers in each country, supported by NVivo ® (version 12). Initial meetings in each country discussed and refined the codes. Each country’s codebook was translated into English. Meetings with the researchers from all the countries condensed the codes and identified key categories and themes. Findings were verified using reflective conversations, comparing and contrasting the codebooks, noting and revising the categories in the light of the research question over several meetings, in line with previously published analytic methods . 

Most researchers are career GPs (range of experience between 1-31 years). Some researchers had previously embarked on a career as a hospital specialist but had changed careers. One of the researchers is on a hospital medicine career. We remained aware that as a research group we may have had a vested interest in promotion of GP as a career and diminution of hospital medicine, and despite our best efforts to the contrary, our interpretation may be biased. 

A total of 43 GP trainees participated, Belgium 18, Ireland 9, Lithuania 14, and Slovenia 6. Participants spread over different years of training and gender was split Female: Male 1.5:1 ( , Participant Demographics). Average interview duration overall was 29 min: Belgium 30 min, Ireland 37, Lithuania 45, and Slovenia 13. In coding, an overall average inter-rater reliability of 92.5% was achieved: Belgium 90%, Ireland 94%, Lithuania 94%, and Slovenia 86%. Our analysis revealed four themes: 1) supervision, 2) teaching, 3) tension between service delivery and learning, and 4) differing secondary care/primary care paradigms. Illustrative quotes, referred to in the theme discussion, are in Quotations . Supervision The supervision experience was found to vary between rotations, a consistent finding across all countries . Some supervisors seem uninterested . A sense of responsibility to provide teaching was lacking . Some hospital consultants appeared to be reluctant to consider what the future professional life of the GP trainee might be like . Other hospital doctors, such as registrars, could fill this supervisory role in an effective manner . Approachability was seen as one of the most important attributes of the supervisor . This was present when the trainee felt that questions on clinical matters were welcomed , when the trainee felt safe that he/she will not be ridiculed and felt valued as a GP trainee . Availability of supervision was highlighted as a significant issue in the hospital environment with concerns for patient safety and trainee well-being as well as training quality. In Ireland and Lithuania, night shifts were noted to have dramatically reduced staffing with a resulting impact on clinical confidence compared to the daytime . GP trainees described many positive experiences. They reported being allowed to push themselves to make clinical decisions with back up  and opportunities to acquire experience in best clinical practice . They described a rich learning environment from peers  and being stimulated to read up on clinical presentations [ and ], useful to them as future GPs. Teaching One-on-one teaching was particularly valued as teaching tailored towards the future career as a GP, e.g. clear guidelines on when and how the trainee as a future GP should refer a patient to the hospital . While each national GP training body or institution had a formal curriculum, hospital supervisors rarely referenced it, an experience noted across all countries . Sometimes the hospital rotations did not provide any opportunities for learning which matched the curriculum [ and ]. Insufficient teaching was lamented in all countries . Regular assessment was considered lacking in Slovenia and Lithuania. In Ireland and Belgium, the GP trainees leave the hospital clinical environment once weekly for training from GP educators. This was felt to make the hospital experience more relevant . In Lithuania, seminars are delivered by GP educators on site in the hospitals during the hospital rotations. Slovenia has no dedicated GP training during the hospital rotations. Tension between service delivery and learning Administrative work, such as discharge letters, was considered less valid to their training by GP trainees . A unique finding in our study is that GP trainees felt they often shouldered a disproportionate amount of such service work to release the hospital specialist trainees on their team for clinical work . GP trainees felt the sheer volume of work to be a hindrance to learning in all countries . Conversely, on occasion, there was an insufficient number of patients and too many hospital doctors seeking experience . The range of expertise in some speciality wards could be narrow, limiting learning opportunities e.g. eating disorders or cataract surgical ward . Excessive on-call duties also hinder learning both in terms of time, by missing educationally richer day shifts, and fatigue levels . Interviewees demonstrated excellent insight into their training needs and the likely demands of their future role, stating that shorter specialised rotations would create an opportunity for other more relevant experience . General rotations, those with larger volumes of outpatient experience were mostly highly valued  with some rotations thought to be of little value to a GP trainee at all . The ability to tailor rotations to learning needs, such as in Slovenia, was limited in other countries by clashes with the logistics of service provision . Differing secondary care/primary care paradigms GP trainees noted that approaches to patient care differed in the hospital environment compared to GP. Hospital-based care focuses on completing multiple investigations quickly in contrast to GP where these investigations can proceed more slowly, using time as a diagnostic tool . GP training is challenging due to the breadth of what needs to be learnt. This contrasts with the depth of knowledge required for specialist care in hospitals. Some GP trainees felt that their hospital experience immersed them in detail which was more than they needed to know for a future career in GP . GP trainees valued learning how the hospital system works, providing insight into the patient’s journey on presentation from the emergency department through to the outpatient clinics, in addition to the clinical opportunity of seeing the course of an illness . Trainees also valued learning how to work as a team and building a future professional network . GP placement early in GP training was beneficial, allowing the GP trainee to better self-direct their training to their future role . Some spoke of awareness of being ambassadors of General Practice while in their hospital clinical placement . Belgian GP trainees, placed in GP rotations before commencing the hospital part of their training, demonstrated a strong sense of GP identity during hospital rotations, presenting their view of what a GP approach to clinical care would be to hospital colleagues [ and ]. An Irish interviewee specifically participated in the study to express how he felt having a GP placement prior to his hospital rotations would have enriched his hospital experience on several levels : by understanding the limitations of services available to a GP, by understanding better what a patient might need from a GP action, e.g. a referral to A&E, by giving greater insight into what was relevant for him to learn during his hospital experience and finally by providing an opportunity to educate his peers on the context of GP referrals to his hospital peers. This view was supported by a Belgian interviewee . Unfortunately, there were negative comments about how some hospitals perceived the contribution of GP trainees. In Lithuania. GP trainees were singled out as not belonging in the hospital, e.g. by derogatory comments from consultants or other hospital team members . This affected the trainee’s sense of being a team member  and represents a missed opportunity for the positive relationships created between career hospital doctors and career GPs as noted in Belgium. 

The supervision experience was found to vary between rotations, a consistent finding across all countries . Some supervisors seem uninterested . A sense of responsibility to provide teaching was lacking . Some hospital consultants appeared to be reluctant to consider what the future professional life of the GP trainee might be like . Other hospital doctors, such as registrars, could fill this supervisory role in an effective manner . Approachability was seen as one of the most important attributes of the supervisor . This was present when the trainee felt that questions on clinical matters were welcomed , when the trainee felt safe that he/she will not be ridiculed and felt valued as a GP trainee . Availability of supervision was highlighted as a significant issue in the hospital environment with concerns for patient safety and trainee well-being as well as training quality. In Ireland and Lithuania, night shifts were noted to have dramatically reduced staffing with a resulting impact on clinical confidence compared to the daytime . GP trainees described many positive experiences. They reported being allowed to push themselves to make clinical decisions with back up  and opportunities to acquire experience in best clinical practice . They described a rich learning environment from peers  and being stimulated to read up on clinical presentations [ and ], useful to them as future GPs. 

One-on-one teaching was particularly valued as teaching tailored towards the future career as a GP, e.g. clear guidelines on when and how the trainee as a future GP should refer a patient to the hospital . While each national GP training body or institution had a formal curriculum, hospital supervisors rarely referenced it, an experience noted across all countries . Sometimes the hospital rotations did not provide any opportunities for learning which matched the curriculum [ and ]. Insufficient teaching was lamented in all countries . Regular assessment was considered lacking in Slovenia and Lithuania. In Ireland and Belgium, the GP trainees leave the hospital clinical environment once weekly for training from GP educators. This was felt to make the hospital experience more relevant . In Lithuania, seminars are delivered by GP educators on site in the hospitals during the hospital rotations. Slovenia has no dedicated GP training during the hospital rotations. 

Administrative work, such as discharge letters, was considered less valid to their training by GP trainees . A unique finding in our study is that GP trainees felt they often shouldered a disproportionate amount of such service work to release the hospital specialist trainees on their team for clinical work . GP trainees felt the sheer volume of work to be a hindrance to learning in all countries . Conversely, on occasion, there was an insufficient number of patients and too many hospital doctors seeking experience . The range of expertise in some speciality wards could be narrow, limiting learning opportunities e.g. eating disorders or cataract surgical ward . Excessive on-call duties also hinder learning both in terms of time, by missing educationally richer day shifts, and fatigue levels . Interviewees demonstrated excellent insight into their training needs and the likely demands of their future role, stating that shorter specialised rotations would create an opportunity for other more relevant experience . General rotations, those with larger volumes of outpatient experience were mostly highly valued  with some rotations thought to be of little value to a GP trainee at all . The ability to tailor rotations to learning needs, such as in Slovenia, was limited in other countries by clashes with the logistics of service provision . 

GP trainees noted that approaches to patient care differed in the hospital environment compared to GP. Hospital-based care focuses on completing multiple investigations quickly in contrast to GP where these investigations can proceed more slowly, using time as a diagnostic tool . GP training is challenging due to the breadth of what needs to be learnt. This contrasts with the depth of knowledge required for specialist care in hospitals. Some GP trainees felt that their hospital experience immersed them in detail which was more than they needed to know for a future career in GP . GP trainees valued learning how the hospital system works, providing insight into the patient’s journey on presentation from the emergency department through to the outpatient clinics, in addition to the clinical opportunity of seeing the course of an illness . Trainees also valued learning how to work as a team and building a future professional network . GP placement early in GP training was beneficial, allowing the GP trainee to better self-direct their training to their future role . Some spoke of awareness of being ambassadors of General Practice while in their hospital clinical placement . Belgian GP trainees, placed in GP rotations before commencing the hospital part of their training, demonstrated a strong sense of GP identity during hospital rotations, presenting their view of what a GP approach to clinical care would be to hospital colleagues [ and ]. An Irish interviewee specifically participated in the study to express how he felt having a GP placement prior to his hospital rotations would have enriched his hospital experience on several levels : by understanding the limitations of services available to a GP, by understanding better what a patient might need from a GP action, e.g. a referral to A&E, by giving greater insight into what was relevant for him to learn during his hospital experience and finally by providing an opportunity to educate his peers on the context of GP referrals to his hospital peers. This view was supported by a Belgian interviewee . Unfortunately, there were negative comments about how some hospitals perceived the contribution of GP trainees. In Lithuania. GP trainees were singled out as not belonging in the hospital, e.g. by derogatory comments from consultants or other hospital team members . This affected the trainee’s sense of being a team member  and represents a missed opportunity for the positive relationships created between career hospital doctors and career GPs as noted in Belgium. 

Main findings This qualitative study gives insights into the views of GP trainees from different European countries of how their hospital experience contributes to their professional development as a GP. Valued It was clear that GP trainees valued their hospital-based training rotations despite the conditions experienced. This was most noted in Ireland and Belgium. This counters a previous argument by Goldie  for situating UK GP training entirely in General Practice. Identity dissonance Cruess et al. (2018) recommend adopting the ‘communities of practice-theory’ as the overarching educational theory in medical education . Each hospital department where a trainee is placed is a ‘community of practice’ and our research shows that these were not always the ideal training environment for GP trainees. Support of doctors in training should consist of an inclusive welcome to the community, access to activities appropriate to the level of the learner, instruction, role modelling and mentoring, and charting progress through assessment and feedback . This is not consistently present during hospital rotations for GP Trainees. Unique learning opportunities Some of the learning on hospital rotations, e.g. current best practice in a specialty, or the full range of presentations which can occur, could not have been learnt in GP. The hospital rotations supported the development of clinical confidence, learning how to work in teams and learning what happens to a patient admitted to hospital. Also, the hospital experience assists in formatting professional connections for those who would practice in the future as a GP in the locality. Context An important finding in this study is the need to situate the learning from the hospital experience in the context of general practice. Contact with GP educational supervisors, either through off-site protected half-day release, or through GP rotations early in training, assisted identity formation as a GP and helped trainees use learning opportunities better. Belgian trainees described educating their hospital colleagues on primary care approaches. Cross-education between primary and secondary care by hospital-based GP trainees (with experience in General Practice) could be a valuable opportunity to deepen understanding of each other by both environments. Supervision Quality of supervision is the most pivotal aspect affecting the value of the hospital rotation. In keeping with AMEE guidelines , the authors recommend that hospital supervisors be aware of the requirements of the training body, and supervision should be structured with regular timetabled meetings . Based on the GP trainee’s comments, there is room for improvement in the quality of supervision for GP trainees on hospital placements across all countries. Strengths and limitations Strengths of the study include the spread of data collection across four European countries with a range of investment of GP placement time within GP training, from countries with a high proportion (Belgium, Ireland) to countries with lower proportions (Slovenia, Lithuania). Limitations of this study include that the interviews were conducted in four different languages and some distortion of the meaning may have occurred in translation. Individual country GP programmes can be limited by availability of training positions which gives significant heterogeneity and resulting experiences. Another limitation is that the subjects interviewed were all trainees. Widening participants to recently qualified GPs now working in General Practice may have uncovered more recognition of the differences between primary and secondary care. A further limitation is that the COVID-19 pandemic may have affected the responses in our data, as some of the more usual formal teaching was lost and so may be under-reported. 

This qualitative study gives insights into the views of GP trainees from different European countries of how their hospital experience contributes to their professional development as a GP. 

It was clear that GP trainees valued their hospital-based training rotations despite the conditions experienced. This was most noted in Ireland and Belgium. This counters a previous argument by Goldie  for situating UK GP training entirely in General Practice. 

Cruess et al. (2018) recommend adopting the ‘communities of practice-theory’ as the overarching educational theory in medical education . Each hospital department where a trainee is placed is a ‘community of practice’ and our research shows that these were not always the ideal training environment for GP trainees. Support of doctors in training should consist of an inclusive welcome to the community, access to activities appropriate to the level of the learner, instruction, role modelling and mentoring, and charting progress through assessment and feedback . This is not consistently present during hospital rotations for GP Trainees. 

Some of the learning on hospital rotations, e.g. current best practice in a specialty, or the full range of presentations which can occur, could not have been learnt in GP. The hospital rotations supported the development of clinical confidence, learning how to work in teams and learning what happens to a patient admitted to hospital. Also, the hospital experience assists in formatting professional connections for those who would practice in the future as a GP in the locality. 

An important finding in this study is the need to situate the learning from the hospital experience in the context of general practice. Contact with GP educational supervisors, either through off-site protected half-day release, or through GP rotations early in training, assisted identity formation as a GP and helped trainees use learning opportunities better. Belgian trainees described educating their hospital colleagues on primary care approaches. Cross-education between primary and secondary care by hospital-based GP trainees (with experience in General Practice) could be a valuable opportunity to deepen understanding of each other by both environments. 

Quality of supervision is the most pivotal aspect affecting the value of the hospital rotation. In keeping with AMEE guidelines , the authors recommend that hospital supervisors be aware of the requirements of the training body, and supervision should be structured with regular timetabled meetings . Based on the GP trainee’s comments, there is room for improvement in the quality of supervision for GP trainees on hospital placements across all countries. 

Strengths of the study include the spread of data collection across four European countries with a range of investment of GP placement time within GP training, from countries with a high proportion (Belgium, Ireland) to countries with lower proportions (Slovenia, Lithuania). Limitations of this study include that the interviews were conducted in four different languages and some distortion of the meaning may have occurred in translation. Individual country GP programmes can be limited by availability of training positions which gives significant heterogeneity and resulting experiences. Another limitation is that the subjects interviewed were all trainees. Widening participants to recently qualified GPs now working in General Practice may have uncovered more recognition of the differences between primary and secondary care. A further limitation is that the COVID-19 pandemic may have affected the responses in our data, as some of the more usual formal teaching was lost and so may be under-reported. 

This study shows that GP trainees valued their hospital experience, especially where approachability and availability of hospital teachers improves the quality of supervision. It uniquely shows that GP trainees have additional challenges as trainees in the hospital environment. These include an identity dissonance of being a GP trainee in the hospital environment, shouldering a greater service work administrative burden compared to their hospital specialty peers, and on occasion, being excluded from the community, which should support the learner. 

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