gms | German Medical Science

GMS Zeitschrift für Medizinische Ausbildung

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 1860-3572

Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildungplus

research article medicine

  • corresponding author Jost Steinhäuser - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Thomas Ledig - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Joachim Szecsenyi - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Christiane Eicher - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Peter Engeser - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Marco Roos - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Jessica Bungartz - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland
  • author Stefanie Joos - Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Deutschland

GMS Z Med Ausbild 2012;29(3):Doc43

doi: 10.3205/zma000813, urn:nbn:de:0183-zma0008135

This is the translated version of the article.
The original version can be found at: http://www.egms.de/de/journals/zma/2012-29/zma000813.shtml

Received: August 22, 2011
Revised: November 23, 2011
Accepted: December 21, 2011
Published: May 15, 2012

© 2012 Steinhäuser et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Background: Since 2008 the Verbundweiterbildungplus programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildungplus.

Methods: The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants.

Results: The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies “Manager“ and “Scholar“.

Conclusion: A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.

Keywords: General Practice, Train the Trainer, Feedback Training, Management, Postgraduate Medical Training


Introduction

Strategies to face the shortage of primary care physicians need to be tailored to different levels of action in order to enhance the attractiveness of the specialty and to gain more primary care physicians in the future. For several years the need for a quality orientated catalogue of requirements has been pointed out [1], [http://www.degam.de/dokumente/aktuell_2009/Report%20German%20GP%20Vocl%20Training%20Commission%20July%20final-amalgamated%20not%20confidential.pdf). A cluster of actions to optimize the quality of training was decided on the 114 Ärztetag in the city of Kiel. These include gaining tutors who attend trainees collegially, structured rotations plans through different disciplines by rotation networks and regular didactic teaching of the trainers [http://www.bundesaerztekammer.de/downloads/114Beschlussprotokoll20110704.pdf].

Such didactic teaching for trainers is in Great Britain, Denmark and the Netherlands also known as „train the trainer (TTT) -programmes and are obligatory to become a trainer [2]. They cover didactic, juristic and medical topics.

Since 2008 the programme Verbundweiterbildungplus of the competence centre general practice Baden-Württemberg offers for all interested trainees of the federal state of Baden-Württemberg optimized training in structural and contential matters [3]. Within this programme vocational trainees, aiming to become a general practitioner (GP), get six days off for additional teaching every year through the complete five year training period. They are instructed in GP medical expertise and additionally in the in Canada developed CanMEDs roles [4], [5]. Besides medical expertise these CanMEDs describe the conceptual framework physician’s professional behaviour in six roles (see figure 1 [Fig. 1]).

In July 2011 trainers of the programme Verbundweiterbildungplus offered a TTT-workshop for the first time.

This article describes structure, content and evaluation of this first TTT-workshop and shows consequences for developing and conducting future TTT-programmes. This article also describes aspects of how trainers teach in their daily practice and their self-assessment according to their estimation of how well they can teach CanMEDs competencies.


Methods

Conception of the TTT-workshops

The TTT-workshop was designed and conducted by eight physicians of the Department of General Practice and Health Services Research in Heidelberg. This group consisted out of two trainees and six GPs. Four of the physicians have the accreditation to teach trainees in their practice and one had the Master of Medical Education degree. For the conception of the first TTT- workshops the first step according to curriculum developing by Kern et al. was to raise the demand of the trainers. This was done by a survey performed 2010 with trainers [6], [7]. The most often stated demand was to develop and implement a curriculum, followed by the need of information about juristic and financial questions connected with the training [6]. European TTT-programmes and experiences from teaching feedback to GPs involved in students teaching during their GP courses and the final undergrad year (“practical year”) were analysed [2], [8]. Experiences gained with teaching CanMEDs during the teaching days of vocational trainees of the Verbundweiterbildungplus programme were also used for the TTT concept.

From the didactic point we chose a constructivitic approach. In the beginning the exchange of experiences was offered by activation of existing knowledge. Differences in existing knowledge were adapted via short input presentations followed by an assimilation phase as a third step including self-experience in role play or map exercise to insure the transfer into the own practice. At the end of the workshop participants had the opportunity to reflect the whole process.

CanMEDs-questionnaire

A 22 item questionnaire was developed, asking trainers how they instruct their trainees (part 1) and how well they thought they were teaching the specific CanMED competencies (part 2).

The first part of the questionnaire focused on the structural, organisational and didactic aspect of training. The questions included: structured familiarization, setting learning objectives, providing feedback, personal instruction, reprocessing faults, inclusion into a practice team, profiting from knowledge of the trainee and the final question „I believe I am a good teacher“.

Part two included, besides socio-demographical items questions, how trainers judge their ability to teach CanMEDs competences. Each CanMEDs competence was represented by one question. This questionnaire was handed out after a presentation on CanMEDs competencies.

All questions could be answered on a five-point Likert-Skala ranging from 1 “very good“ or “fully true“ to 5 “very bad“ respectively “not at all true“. The original questionnaire can be requested by the authors.

Evaluation form

The TTT-workshop was evaluated by an evaluation form regularly used to evaluate the “Heidelberger Tag der Allgemeinmedizin” [9]. With this form information, didactic elements, the possibility to participate actively, the atmosphere and the degree of importance for the practice was raised. These questions could also be answered on a five-point Likert-Scale ranging from 1 “very satisfied“ to 5 “very unsatisfied“.

Recruiting

The 190 GP trainers inscribed in the programme Verbundweiterbildungplus were informed about the voluntarily and cost free TTT-workshop by mail.

Statistics

Statistics were performed by the programme SPSS, Version 18.0 (SPSS Inc., Chicago, IL/USA) and were descriptive. Percentages are given as valid percentages, which means that they are summed up to 100%. Responses are summarized within three categories in the result section (“agree” (“1”), “neutral” (“2”) and “disagree” (“3”)).


Results

Course schedule

At the first day after a get to know each other round, experiences with training was raised. Afterwards small presentations followed concerning the background of the Verbundweiterbildungplus, the teaching days and the CanMEDs competencies. Secondly participants in supervised small groups worked out how CanMEDs competencies can be instructed in an optimised way. While matching these results in the plenum, we got a best practice model for the situation of a general practice in Germany.

The second day started with an input to the psychological background of providing feedback and an instruction of how to provide a good feedback [8]. After this introduction the participants had the chance of self-experience in role plays. Participants rotated in small groups through three stations with different core areas of providing feedback. In one station participants provided feedback towards a standardized trainee. The other participants had the chance to give more feedback to the standardized trainee who had to behave differently in his role e.g. not accepting the feedback. So the participants had the chance to provide feedback in difficult situations. In the other two stations short real life video sequences were shown for training and discussing specific feedback and identifying unhelpful feedback. All stations were supervised by a trainer.

In the last module participants got the opportunity to get practical hints to avoid critical situations in the practice connected with the vocational training. This input included the management of faults and juristic and organisational aspects.

Participants

49 of the 190 invited trainers, applied for the TTT-workshop (26%). Because of reasons of capacity only 20 could participate and were chosen by the date of their respond. Participants were in two third male, on average 57 years old and had trained already between 0 und 20 (average 6) vocational trainees. One third did work in a rural area and almost 60% in an urban surrounding. The missing 6% did not fill in this item. About one quarter of the participants did work in a single handed practice, the other with different types of practices including at least one colleague (see table 1 [Tab. 1]).

Approaches towards training of trainers

From the participants 41.4% affirmed the question of whether they have a structured procedure while incorporating a vocational trainee; the arrangement of learning objectives at the beginning of the rotation was affirmed by 41,4% as well. Almost one quarter of the trainers (24,1%) agreed that they provided feedback to check the progress at least once a month. That all incoming activities were instructed by the trainer, stated 89,6% of the participants. The majority (96,6%) agreed that they reviewed occurring faults with the vocational trainee. Integrating the trainee into the practice team is done by 79,3%. From the participants 68,9% believed to be a good teacher (see table 2 [Tab. 2]).

Self - assessment, being able to teach CanMEDs competencies

The trainers of the first TTT-workshops majorly agreed that they are able to teach the competencies “cooperation” (93,1%), “communication” and “health advocate” (each 89,7%) followed by “professionalism” (82,8%) and “GP medical expertise” (79,3%). The competencies “scholar” (65,5%) and “manager” (55,2%) got lower acceptance. More details can be found in table 3 [Tab. 3].

Evaluation

The collegial exchange was assessed with 1,3 (German school grades range from 1=”very good” to 6=”poor”) followed by total experience of the workshop with 1,4 rated as very good. The degree of information and the practical relevance was rated with 1,6 and the one to fault management with 1,5. The degree of information and the practical relevance of feedback training was evaluated with 1,6 each. The degree of information and practical relevance of the juristically aspects was rated 1,8 and 1,7. The degree of information and practical relevance of the input about the “CanMEDs competencies input” was evaluated with 2,1 and 2,0.


Discussion

This article describes the conception and first experience of a very good to good evaluated TTT-workshop for GP trainers. Additionally a description of the status quo of how trainers train as well as a self-estimation of a trainer’s ability to teach CanMEDs competencies is shown.

The majority of the participants, which were on average 57 years old, were male, working in a practice with one or more colleagues in an urban surrounding and has trained several trainees so far. The age of the trainers is comparable with those in the federal state of Baden - Württemberg who participated at a survey in 2010 [6]. The percentages of female trainers were fortunately with 24% higher than the average percentage of female trainers in Baden-Württemberg which is almost 20% [6]. However, this number is still less than the amount of the 35% female GPs working in Baden – Württemberg [https://www.gbe-bund.de/gbe10/abrechnung.prc_abr_test_logon?p_uid=gast&p_aid=4711&p_sprache=D&p_knoten=TR200]. If this difference can be explained by surrounding reasons such as e.g. part time working and the reasons for part time working should be a matter for future research.

One of the most important abilities of a trainer is generally the ability to provide feedback [10][. Additionally a feedback trained trainer is believed to play a major role during the process to decide pro or con the GP specialty [11], [12]. Therefore the module teaching to provide feedback is one central element of the TTT-workshop.

The self estimation about the way trainers train was good. The aspects learning objectives setting, providing feedback and the structured incorporation of a vocational trainee seem to need optimisation. This necessity for optimizing might indicate some need to practice only or it indicates that the work as a trainer needs financial aid to get the necessary „protected“ timeslot. Both hypothesises should be matter of further research. A competence based Curriculum, which states all the basic abilities a vocational trainee should learn during his qualification could also help the trainer to do his job. A national wide project such as “competence based GP Curriculum“, which should hit these expectations sufficiently should be available in 2012 [13]. If such a curriculum is available instead of only learning objectives, training can focus on competencies in future.

The direct instruction of a vocational trainee, handling of faults and the integration of the trainee into the praxis team seem to be of little problem in daily practice circumstances. The information, that 97% of the participants can profit from the knowledge of their trainees fits to the finding that collegial exchange is the highest motivation for vocational training [6], [14]]. The self-estimation in regard of the ability to teach competences is purely positive for “communication”, “collaboration with other professions”, “health advocate”, “professionalism”, “scholar” and “medical expertise”. Relating to the competences “management” and “scholar” participants are less self confident. Remarkably 30% stated that they believe that they cover this competence only partly and 13,8%, that they do not believe that they can teach the competence of a manager at all. This might indicate that trainers themselves are not well enough instructed in this important area. Furthermore this result indicates that abilities from the manager competence was not estimated to be important and therefore not worth being taught. How important this competence really is can be found in a survey among vocational trainees where 63% get deterred from a settlement by the assumed entrepreneurial risks [15]. There a huge, nation wide need of teaching this manager competence to trainees and trainees gets visible [16].

The evaluation of the workshop and its modules was rated very good to good. One impression that came across during conversations with the trainers was the high need to network and to exchange experiences. Therefore all future concepts of TTT-programmes should, besides providing knowledge and abilities, pay attention towards this phenomena and offer time for that to enhance motivation of the trainers. Concerning the next steps, this analysis of the TTT pilot will be included into the regular TTT –programme and prospectively followed.

Strength and weaknesses

This article describes the conception and accomplishment of a TTT-workshop, as a so far unknown activity in the German medical system. As participants were volunteers a selection bias especially of very motivated trainers is likely. The questionnaire with items about the CanMEDs competences was build by the authors and not formally validated. Therefore we can not exclude, also we gave an input on the CanMEDS before the rating of the participants, that some items were not specific enough.


Conclusion

For the GP discipline TTT-programmes are an important and so far not used action to strengthen the specialty by developing training. Findings concerning self-estimation and teaching of trainers could be helpful for developing future TTT programmes. A Germany wide TTT-programme should consist mainly out of feedback training and teaching of aspects of practice management. Additionally the demand of information towards juristically and organisational aspects should be met. Starting with the experiences raised in this pilot workshop and the positive acceptance of the participants, this workshop will be on a regular basis in future TTT-workshops within the Verbundweiterbildungplus programme.

Such programmes are necessary not only for GP trainer but for all other disciplines too.


Acknowledgement

The authors thank all trainers participating in the Verbundweiterbildungplus programme. This pilot was funded by the ministries of Science, Research and Art, and Rural Area, Alimentation and Consumer Protection Stuttgart, Germany within the project “Competence Centre General Practice Baden-Wuerttemberg”.


Competing interests

The authors declare that they have no competing interests.


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