Introduction and objectives
Dear Out of Hours teacher/ Supervisor,
Firstly, many thanks for agreeing to supervise a medical student. As part of an overall change in the undergraduate medical curriculum at Bristol we are working towards improving the knowledge and experience of Out of Hours / Integrated Urgent Care (IUC) for year 5 medical students by offering each student at least one session in an IUC setting.
Your student is likely to have no experience of the IUC environment prior to this shift with you. They join you during their ‘Preparing for Professional Practice’ (PPP) GP attachment. They have completed their finals exams, and are in the final phase of medical school before becoming Foundation Year 1 doctors in August. During PPP they spend time shadowing junior doctors to learn how to put all the theory into practice. They also spend nine weeks in a General Practice where the emphasis is on consulting independently and practising decision making. The aim is to refine their clinical skills under the supervision of experienced clinicians, understand polypharmacy and multimorbidity and the primary/secondary care interface which they will soon be right at the forefront of when they are clerking admissions and preparing patients for discharge. We feel it is essential, therefore, that students have at least some appreciation of the vast amount of activity that happens in the Primary Care IUC environment, and what happens when a patient phones 111 as advised by the junior doctor in their safety-netting advice.
We are also keen to ensure that students understand the breadth and variety that being a GP can offer. As you will be aware, there is a recruitment crisis in Primary Care and there is good evidence to suggest that positive experience and role modelling in the undergraduate setting encourages students to pursue a career in General Practice.
The learning objectives for this session are twofold
- To gain some insight into the workings of the IUC service in your area – for example, the telephone work, breadth of presenting problems, the acuity of the patients, the time pressure, approaches to risk and documentation compared to in hours GP and the computer system.
- To gain further experience of assessing and managing acute presentations
Roles and responsibilities
Their experiences on shift will naturally be different depending on what presents on the shift that they join you for.
General principles
Students will mainly be in an observatory role listening to telephone calls and discussing with their supervising clinician. A medical student may conduct an assessment at a treatment centre on their own. However, the supervising clinician retains overall responsibility for the care of all patients that the student has contact with. No patient can leave the care of the organisation without the supervising clinician reviewing the patient, and reviewing/approving the assessment and management plan. This includes taking overall responsibility for the electronic patient record (the notes). If you are familiar with supervising GP trainees, the medical students will never be anything but ‘Red’ on the traffic light grading of supervision.
Given the current pressures on IUC in terms of work load it may not be feasible for students to assess a patient on their own. This is because there may be other patient’s booked into be seen in the same room shortly after. Please make a judgment call with regards to this during your shift with support from the shift manager.
Students have been asked to wear their Medical Student ID badge and have been asked to sign a confidentiality statement before arriving on shift.
You can expect an enthusiastic interested student who should have plenty of knowledge but is likely to need to develop how they apply this in real life. We would be surprised if you have any concerns about a student’s attitude to you or your patients but if you do, please do report using the guidance below.
IUC Sessions
Students will be allocated a 4-hour IUC session either at Osprey Court or 1:1 with a supervisor at a treatment centre.
Treatment Centre work
Students will also be placed at treatment centres, working 1:1 alongside an IUC supervisor. As discussed above a student may see a patient that you have selected as suitable, in a room by themselves to take a history and perform an examination. The patient should be made aware that a student would like to see them and consent sought for this. The student should come up with a management plan by themselves but the history, examination findings and management plan should be reviewed with the supervising clinician before initiation. We would hope that competent, confident students who can present well may speed up your workload but as with any student you will have a feel for the quality of the information being relayed to you. See later, if you have concerns that a student is well below the level you might expect.
If there isn’t a room for them to use, they can observe you assessing a patient with patient consent.
Telephone triage/ consulting
Please let students listen in to your telephone consulting, informing the patient that a student is listening. Students are not to perform telephone triage. They will be introduced to the skill but will have minimal experience and they are unlikely to have use for this skill in the near future. Please discuss the telephone cases with your student to make this experience as valuable educationally as possible.
Sesui is used for all calls that are made from Osprey Court. In order for trainees to listen to calls through sesui they need to log in to a training account from which they can “drop in” to the call. It is important that if they drop in to a call, they select the “mute” option immediately to prevent the caller from hearing two people. Training credentials can be obtained from the shift manager. From our bases trainees can listen to calls through loud speaker.
Mobile shifts
Due to the lifting of covid restrictions, students may now accompany you in the car on a visit as long as you, the student and driver are comfortable with this.
Covid Considerations
Please make sure that your student wears full PPE when seeing a patient face to face in the infection room. If you or the student have any cough or cold symptom, please consider wearing face masks.
Assessment of the student
We hope the OOH shift will be a formative learning experience for the student. You are not required to complete an assessment for the student for this shift, except to record their attendance. However, by the end of their PPP block students need to have been witnessed performing various practical procedures competently. Therefore, some students may ask to have procedures signed off in their CaPS (clinical and procedural skills) logbook if the clinician has witnessed them performing a specific skill (e.g. blood pressure, ECG, urine dip).
The students also have an online workbook they need to complete by the end of year 5. This consists of 16 Entrustable Professional Activities (EPAs) that students need to perform at the level expected for an F1 doctor. Examples include
- Gather a history and perform a mental state and physical examination
- Document a clinical encounter in the patient record
- Prioritise a differential diagnosis following a clinical encounter and initiate appropriate management and self-management in partnership with the patient
- Recognise a patient requiring urgent or emergency care and initiate evaluation and management
If you have observed the student consulting with a patient or discussed a case with them, they may ask you to sign off activities in their workbook. Activities can only be recorded once and cannot contribute to more than one EPA.
It is up to you as the supervising clinician whether you are happy to complete these assessments or not. This is not a requirement as the students should have ample opportunity elsewhere within their primary care block to complete such paperwork.
Evaluation of the placement
SevernSide will email students a feedback form after their IUC shift.
If you have any feedback about having a student, please email phc-teaching@bristol.ac.uk. Although we do not expect you to have any concerns about the performance, behaviour or wellbeing of your student, we have to plan for this eventuality. As such full details about this scenario follow.
We would really value your feedback on your experience of supervising medical students in IUC. We will contact you for some feedback at the end of the 7-week block.
What to do if you have concerns about a student
- There are occasions that you may be concerned about a student’s performance or wellbeing.
- Always try to discuss your concerns with the student concerned.
- If you are not easily able to resolve your concerns with the student, try to inform the student that you will be seeking further advice
- There is a useful below which should guide you to the most appropriate course of action depending on the particular issue. https://sway.office.com/sGWAcdTyzsmV4aVf?ref=Link
- There is a student wellbeing service available 24hrs a day and this should be the first point of contact for any welfare issues. You do not need to have the students consent to contact them. This can be via a Wellbeing Access form, by emailing wellbeing-access@bristol.ac.uk, or calling 0117 456 9860 (open 24 hours). Information on the range of support can be found at www.bristol.ac.uk/wellbeing.
- Please note that the medical school encourages teachers to have a low threshold for filling in student referral forms.
- Please do not hesitate to contact us if you want to discuss your concerns; phc-teaching@bristol.ac.uk
Thank you for supervising Medical Students
Thank you again for agreeing to supervise medical students in IUC and for enthusing the next generation of doctors about general practice and work in IUC. We hope this is a valuable and enjoyable experience for both you and the students. If you have any questions or want to discuss further, please contact Jo Edwards, Lead GP for Integrated Urgent Care - joanna.edwards3@nhs.net
Very Best Wishes
Jo Edwards, Lead GP SevernSide IUC and Karen Pond, Community GP Lead for Gloucestershire and GP 5 Co Lead, Bristol Medical School.