Table 4 Details of structure and content of pilot GP training sessions
Timing | Topic | Detail | Methods & Resources |
|---|---|---|---|
Session 1 | |||
10 Min | Introductions | ▪ Personal introductions, roles, etc. ▪ Brief outline of the practice and its population ▪ Special interests of GPs | Pre-trial background sheet completed by practice ▪ Informal chat to get people warmed up |
10 Min | Brief outline of study, its background and scope | ▪ Origins of research in STarT Back ▪ Explain prognostic risk ▪ Clinical conditions and sites involved ▪ What we are investigating, in general terms | Few slides – scant detail ▪ Interactive presentation and brief Q/A |
10 Min | GPs’ current management of these conditions | ▪ Diagnostic approaches – bio-mechanical/ bio-psycho-social – use shoulder pain as example ▪ Investigations routinely used – what and where? ▪ Advice generally given to these patients ▪ Sickness certification ▪ Medication preferences and usage ▪ Physiotherapy etc availability and usage ▪ Referral options and patterns for different pain sites – MSK, surgical etc ▪ Significant constraints they experience ▪ Patients’ expectations – e.g. Imaging, certificates, referral | Pre-trial background sheet ▪ General discussion to gauge GPs’ philosophy and general approaches – helps build relationship and aid to tailoring our approach to training ▪ Avoid detail on specific conditions within MSK Flip chart to explore treatment/referral options for the practice |
20 Min | GPs’ usual consultation habits | ▪ Map out their usual consultation process/flow ▪ Is computer used during or after consultations? ▪ Read coded diagnosis entered at provisional stage or not ▪ Any existing use of templates and decision aids? ▪ Use of interactive tool plus printed advice eg PILS | ▪ More informal discussion A4 sheet with a few prompt statements for GPs Pads of paper for GPs’ notes Sticky notes pads to capture notes and queries for later |
20 Min | Stratified care approach | ▪ What is stratified care and how does it differ? ▪ Why it may have advantages for patients and NHS ▪ Basis for prognostic stratification tool ▪ Expected proportion in each risk group ▪ The tool identifies potential treatment targets ▪ How this complements usual diagnostic clinical practice ▪ Matched treatment options and how we devised them ▪ No change in local pathways during the study – treatment options are pointers to be used with these pathways | ▪ Interactive presentation and Q/A Slides: Knowledge about stratified care Establish credibility of tool and matched treatments Emphasise “Risk” is of chronicity/complexity not pathology Explain complementarity with diagnostic process No new pathways at this stage |
45 Min | The STarT MSK tool in practice | ▪ Overview of questionnaire and matched treatments ▪ Key GP behaviours the tool tries to nudge/change ▪ Providing the tool score to onward treating clinicians ▪ Trying out the tool – paper exercise: ▪ GPs work in pairs, each with a vignette ▪ One asks questions and completes paper tool, other responds from vignette ▪ Swap roles for second vignette ▪ Compare scores and experience of using tool ▪ Demonstration of integrated template by facilitator ▪ All GPs trying it out with support | ▪ Discussion around slides: Pyramid slide for overview Questionnaire and matched treatments ▪ Giving patients score and recommended options Communicating score in referrals Paper copies of vignettes and risk tool Live EMIS system with template ▪ Demo of template use ▪ All GPs trying out template, using vignettes, with no attempt at consultation elements Vignettes needed: Low risk knee pain, Medium risk shoulder pain, High risk multisite pain with co-morbidity |
5 Min | Suggested preparation for Session 2 | ▪ Try template a few more times with dummy patients ▪ Look at treatment options and linked patient info | ▪ Replace this with a short break if running 2 sessions together – would need refreshments |
Session 2 | |||
10 Min | Reflections from Session 1 | ▪ Questions about stratified care concept ▪ Feedback from trying out tool ▪ Practical issues and any doubts | ▪ Reminder of key elements we covered in Session 1 ▪ Discussion of any issues ▪ Skip if running 2 sessions together |
60 Min | Simulated “consultations” using vignettes | ▪ GP or one of team gives outline from a TAPS vignette, as a patient might present ▪ What to say to the patient about the tool and risk groups ▪ GP uses template to get score and treatment options ▪ GP explains and negotiates options ▪ Facilitator might try asking/challenging for other options ▪ Each GP has at least one turn at simulation | ▪ Skills session ▪ Emphasise simulation and not role play ▪ Use selection of low/medium/high risk vignettes as basis Set up clinical computer in a consulting room if possible and run as a consultation, each taking a turn ▪ GP or facilitator gives outline story ▪ Facilitator can present challenges for consulting GP ▪ Group works together on suggestions – problem-solving approach Prompt sheet for consultations |
10 Min | Discussion of simulated consultations | ▪ GPs’ belief and trust in score and recommendations ▪ Practicalities of negotiating recommendations with patients ▪ Dealing with inappropriate demands | ▪ Discussion to explore beliefs and confidence in approach and tools, having had the experience ▪ Anticipated challenges and how to handle them |
15 Min | Diagnostic issues and priorities vs stratification options | ▪ Discussion about complementarity of clinical diagnosis and prognostic stratification ▪ Examples of “clinical override” of risk stratification | ▪ Discussion Few clinical vignettes to illustrate situations where clinical diagnosis or situation might take precedence, eg: PH of breast/prostate cancer Chronic problem with many failed treatment attempts Frailty/multi-morbidity |
10 Min | GP management of low risk patients | ▪ Effective reassurance ▪ GPs’ confidence in managing low risk ▪ Resources available for low risk management ▪ Other primary care team members involved in low risk? | ▪ Discussion about how GPs will manage low risk ▪ How to provide effective reassurance ▪ Look at advice materials Printout of PILS + Leaflets |
10 Min | Management of medium and high risk patients | ▪ Addition of layers to complement low risk management ▪ Directed at specific pathology and wider issues e.g. co-morbidity, psycho-social, employment, etc | ▪ Discussion around recommended treatment options Paper copies of matched treatments to illustrate |
5 Min | Action plan | ▪ Dealing with queries ▪ Additional support if needed ▪ Who to contact etc | |