Introduction of online workplace-based assessments for practicing primary care physicians in countries lacking structured primary care

Hina Jawaid is a family physician, an Associate Professor, and Head of the Family Medicine Department at Health Services Academy, Islamabad, Pakistan.

Shehleen Arbab Khan is a portfolio GP for the NHS; Clinical Lecturer at the University of Manchester; a Fitness to Practice Panel member; and a GP and Responsible Officer Appraiser for NHS England North West.

Workplace-based assessments (WPBAs) are an important and structured form of teaching, learning, and assessment. As a formative tool, they are an ideal method for identifying gaps in an individual trainee’s training.

It is standard practice to have face-to-face, case-based discussion sessions between a supervisor and a trainee. Although, in a setup where there is a limited supply of primary care trainers and educators, such as in lower- and middle-income countries (LMICs), it is a significant challenge to conduct one-to-one sessions for larger groups.

In certain LMICs in the world, medical graduates enter into family medicine/general practice after completing their house job. Therefore, having a basic medical degree and no further training or formal qualifications, the quality of patient care provided by them can potentially be less than exemplary.

Although a considerable number of institutions in these regions are offering training programmes in family medicine and incorporating WPBAs as part of formative assessments, it is important to note that a significant proportion of practicing general physicians holding MBBS qualification still undergo non-training postgraduate pathways.

These qualifications obtained through experience-based pathways in family medicine lack structured training, including WPBAs. Practicing family physicians acquiring such degrees therefore mainly gain theoretical knowledge updates without any primary care-focused structured training or clinical supervision. Introduction of WPBA to these groups can be challenging due to a lack of structured training pathway for all.

Bearing in mind the significant number of clinicians having undergone an experience-based pathway without a structured training programme or assessments, such as WPBAs, a modified version, that is online case-based discussions (CBDs) utilising a template to assess competencies, was therefore introduced.

The reason for selecting CBD as a form of assessment was due to the fact that a number of competencies can be assessed and feedback given, thereby improving competence in a variety of areas, for example: professionalism, communication skills, clinical reasoning, clinical management, and dealing with ethical issues.

Participants of these sessions include those practicing physicians who have no formal postgraduate qualification in family medicine/general practice, as well as trainees enrolled in formal training and those who acquired a postgraduate degree through experienced-based pathways. Participants also include those who are not currently working or on a sabbatical, thereby allowing them to maintain a level of knowledge, as well as links within the profession. Occasionally, family medicine faculty members also attend.

The initiative of online CBD was taken by the then-Assistant Professor in the Department of Family Medicine at the University of Health Sciences Lahore, Pakistan. The first session was conducted in June 2022. Since then, it has been arranged as a monthly activity and, on occasions when time pressures allow, a fortnightly activity. Facilitators involved in conducting these sessions are GPs, with most of them holding MRCGP (UK) and who themselves have been trainers and educators for many years.

The main purpose of these sessions is to provide a platform for those doctors who have not undergone a formal quality-assured postgraduate training programme in family medicine. Therefore, this platform of online CBD allows doctors a safe space to develop and discuss cases seen by them in their clinical practice, thereby obtaining constructive feedback from experienced educators as well as peers. This platform also acts as a peer support group for these doctors, as they can support each other outside of these formal sessions, and introduces them to each other as colleagues, as they may be practicing in different parts of the country, including in rural regions.

What was new for facilitators?

A number of issues were encountered on starting these online CBDs:

1. With regards to the template (taken from Bradford Vocational Training Scheme), some participants found it difficult to interpret or respond to.
2. Inability to obtain cases earlier than the day of discussion.
3. Inadequate consultation skills of participants, particularly around data gathering, dealing with uncertainty, and shared decision making, was noted on a number of occasions.
4. In remote areas, some of the physicians were based in hospital settings and their approach to patient management was therefore not the same as primary care physicians working in the community.

Step by step

A stepped approach of case discussions was then used. This included having a case on the day and going through it collectively. This method was utilised for a while, and once participants were familiar with this approach it was then decided that a week’s notice to submit cases wishing to be discussed would be the minimum requirement.

Feedback from participants

The majority of responses were encouraging. According to the participants, these sessions gave them a platform to discuss a variety of clinical issues and how to overcome deficiencies in knowledge and skills. They felt the discussions were productive, and constructive feedback helped them improve their approach to various aspects of consultation and patient management.

Way forward

Further discussions with medical education experts helped in exploring issues, such as what other areas would these doctors benefit from in order to improve their clinical practice further. It was decided to seek their opinion on aspects they find useful and aspects they would like to see developed further. Whether this approach will lead to the improvement and development of competencies in participants, and thereby result in overall improvement in patient care, is yet to be determined.

Some countries, like Sri Lanka, are using practice-based assessment, a form of formative assessment, to assess clinician’s practice at multiple levels. This form of assessment focuses on a set of values and behaviours that are necessary for maintaining trust between a doctor and patient. Candidates self-evaluate using a template containing eight characteristics of behaviour. It is conducted both face-to-face and via video conferencing. The assessor reviews the candidate’s progress at a later stage in their training. Perhaps, this method, as a more robust next step for our CBD sessions, can be considered, as it will allow for progress to be monitored at a later stage in training and help with formal evaluation of outcomes. This process will, however, require sufficient numbers of trained family physician educators and clinical supervisors.

Featured photo by Sergey Zolkin on Unsplash.