Teaching Practice Organizationin the vocational training of GPs in the Netherlands

April 2014

Fred Dijkers, MD, PhD

general practitioner

Afdeling Public health en Eerstelijnsgeneeskunde

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Leiden University Medical Center

LUMC Afdeling Public health en Eerstelijnsgeneeskunde

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Place of the Dutch GP in the healthcare system

Dutch GPs are gatekeepers in the Dutch healthcare

system. Every Dutchman is inscribed with his or her GP.

A fullltime GP has about 2200 patients inscribed.

Dutch GPs mostly work together in a practice. Some are

also owner of the practice, others work as employee (of

an organization or of another GP).

Dutch GPs offer a 24/7 service for their patients (during

out-of-office hours concentrated in special centres). Afdeling Public health en Eerstelijnsgeneeskunde

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The healthcare system is not a stable system these days.

Care given by the general practice is cheaper than care

given in the hospitals. If the quality of the care is equal,

then there will be a shift form hospital-care to GP-care.

There are more fields in the health care system where

comparible shifts can be made. Think of the domains

public health, mental health and work-related healthcare.

Often this means in GP-practice more (and a new type of)

personnel and a greater building. Choices must be made.Afdeling Public health en Eerstelijnsgeneeskunde

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Practice organization is essential for GPs

Known elements of practice organization are:

• Practice building

• Registration system

• Diagnostic equipment

• Equipment for treatment

• Personnel / staff

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Practice organization is essential for GPs

But practice organization is more, e.g.

• Cooperation with other care professionals

• Patient information

• Programs for patient safety

• Infection prevention

• Quality management

• Change management , time management

• Negotiations

• Finances

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Practice organization has two levels?

Thinking of the different aspect of practice organization

the field seems to have two levels:

• 1. Aspects, relevant for all GPs

• 2. Aspects, relevant for practice owners

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Vocational training of GPs

In the Netherlands the vocational training of GPs takes

about three years. The trainees have some special stages

(emergency care, work in a nursing home), but work most

of the time in two different GP practices under supervision

of an experienced GP.

During their training they come to one of the eight

university institutes one day a week for education.

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Vocational training of GPs

On that day the trainees get education and they have

discussions in groups of 12 together with two group

companions, a GP (mostly not a practice owner) and a

psychologist.

Practice organization is a part of the education, but the

knowledge is not given separately. That would have

resulted in an overflow of the teaching program. So

practice organization is mostly given, embedded in other

subjects.

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Is this way of teaching succesfull?

•No !!

During the process:

• The group companions hardly explain aspects of

practice organzation in the programms.

• They have no experience in this field and it is not their

core business.

Afdeling Public health en Eerstelijnsgeneeskunde

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Is this way of teaching succesfull?

•No !!

During the process:

• The trainees learn theoretically relevant (new) aspects of

practice organization, but they often do not recognize

them in the training practice. So these aspects are

forgotten easily.

Afdeling Public health en Eerstelijnsgeneeskunde

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Is this way of teaching succesfull?

•No !!

After the process:

• New trained GPs say they haven´t had enough practice

organization in their vocational training.

Afdeling Public health en Eerstelijnsgeneeskunde

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Is this way of teaching succesfull?

•No !!

After the process:

• New trained GPs say they haven´t had enough practice

organization in their vocational training.

• We do not know whether this is a true or a false

statement: most new GPs function good. But obviously

they are uncertain about this subject.

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•Change !

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Considerations (1)

• The GP, working as group companion, is mostly not a

practice owner, so he or she misses experience in some

fields of practice organization.

• Some investigations have been done to measure the

interest of trainees in practice organization. This interest

is concentrated in the last 6 monthes of their vocational

training (and in the two years after settlement).

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Considerations (2)

• The students that want to become a medical doctor are

mainly interested in curing patients. If their interest would

have been ´management´ then they probably had

chosen another study.

• Learning of management is easier from projects than just

from theory.

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Considerations (3)

• The university institutes are not very interested in

practice organization. They love publications.

• In the Netherlands a lot of work is done to make general

practice an evidence based profession with a lot of

international publications. Practice organization is often

experience based and strongly related to the healthcare

system in a country. That makes it less suitable for

international publications.

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A new start

• For the teaching of practice organization in the

vocational training of GPs we choose four spearheads:

• 1. All trainees do a project in the training practice

• 2. Extra attentention to those trainees who are interested

• 3. Help training practices optimizing their organization

• 4. Teach the group companions in the institute

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1. A project in the training practice

• All trainees start a project about infection prevention in

their first training practice. In the second one they do a

small project around quality improvement.

• These projects are not easy and they are often not

finished in time. But they give insight in this kind of work.

The accompaniment in the institute is not optimal yet.

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2. Extra attentention for interested trainees

• Interested trainees can make a differentiation in their

vocational training. They can choose for extra lessons in

practice organization during 6 days in the last year of

their training. This is organized in Leiden also for three

other university institutes.

• This differentiation is very popular under trainees. It is a

great succes.

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3. Improvement of the organization in training practices

• The teaching of practice organzation is focussed on the

settled GP in the training practice. The training practice

is the shop floor for the new GPs. She or he works most

of the time in that practice. We offer the settled GP in the

training practice a problem-oriented way of learning. In

this way the trainee can perceive the new developments

in practice organization and can become familiair with

them.

• This programm was also a great succes.But it is not

obligatory for all training practices yet.

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4. Teaching and instruction in the institute

• The teaching of practice organization is not only

focussed on trainees and on training practices, but also

on the group companions in the institute.

• This is the most difficult job. Because we have to

convince the group companions that this knowledge is

usefull and necessary. It takes a lot of energy.

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Instruments

• To reach our goals two instruments has been made

beside the known teaching programms:

• 1. A book

• 2. A course to get new teachers

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Text-book

The knowledge of practice organzation, relevant for GPs is

written down in an book, written by >40 authors. It contains the

most relevant elements of practice organization for GPs and is

made in cooperation with the NHG (the scientific organisation of

Dutch GPs). The text-book is available in printed form and as e-

book.

The e-book has deeplinks in the text to internet sites.

It also offers several multiple choice questions per chapter and

the correct answers (as a test for the right understanding).

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Text-book

practice organization in general practice

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Teachers

• In order to get enough teachers for all the education

programms a new course has been started some years

ago in Leiden. It is a postacademic course in Practice

Organization for settled GPs. This course takes about

one day a week during two years. Today we have some

45 graduates.

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Conclusion

• If you want to teach practice organization in the

vocational training of GPs then you can not just give

theory (lessons and workshops). Probably this

combination is a good idea:

• Give all trainees projects in this field and offer extra

education to the trainees who are interested.

• Offer problem-oriented education to settled GPs.

• Offer education about practice organization to the group

companions in the institute.

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Does it work?

We will see.

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The end

?•Do you have questions?

•Thanks for your attention.

Afdeling Public health en Eerstelijnsgeneeskunde