Are family practice trainers and their host practices any better? comparing practice trainers and non-trainers and their practices

Family physician (FP) trainers and their host practices are expected to be places of excellence in order to provide a predetermined standard of medical education. Some evidence for this hypothesis is already available, which shows differences between FP trainers and non-trainers and their practices, although the data are mainly from the 1990s [1‐4]. Three of these studies found FP trainers to be better qualified than non-trainers for some organizational competencies like equipment and delegation [1, 3, 4]. Many Colleges, such as the College of Family Physicians of Canada or the Royal College of General Practitioners in the UK, have a responsibility in setting the standards for the training, in certification and lifelong education of FPs. Vocational training has become compulsory in the European Union, requiring a high-standard of training and methods to assess the quality of the training [5, 6]. FP training institutes are obliged to provide trainees with professional FP trainers working in excellent practice settings [7, 8]. We need therefore information on the quality and added value of training practices and FP trainers [9]. Providing excellence in training requires more than the definition of standards for FP trainers and their practices alone [10]. In the Netherlands FP trainers receive instruction and training to become a teacher and clinical supervisor, [8] and training practices are stimulated to participate in a practice accreditation program providing detailed feedback to the FP and the practice (Appendix 1) [11‐13]. The feedback offers trainers, training practices, and institutions detailed information that could help to show where improvement in organization is needed [14]. Moreover, it makes explicit what the added value and advantages are of being a trainer for both the training practice and the FP.

The aim of this study was to explore differences in the structure and process measures between FP trainers and non-trainers and their practices, to see whether there is added value in terms of the quality of services provided to patients and in the quality of the practice organization of training practices as a host organization for trainees.

The characteristics of the participating FPs and practices are shown in Table 3. FP trainers were more often male, older, had more experience as a FP, worked longer hours, and had more patients. FP training practices were more often suburban practices with more partners, more patients, more assistance and more management support. The 177 FP trainers scored higher on all except one (UV-lamp for eye diagnostics) of the 142 FP-level items and significantly higher on 47 of the 142 items (Table 1). Training practices scored higher on all 227 practice level items and significantly higher on 61 of the 227 items (Table 2). Most of the differences were found in ‘medical equipment’. The differences between FP trainers and non-trainers that were significant after correction for covariates are described below in more detail for FP and practice level respectively.

Our findings show that FP trainers offer more services and work in better organized practices than non-trainers, but the differences were small for FP trainers and small-moderate for training practices. FP trainers reported providing a wider range of services, including chronic care management, delegating more tasks and having better quality management. FP trainers enjoyed their job more, had more commitment, more job satisfaction and less job stress than their non-trainer counterparts, in spite of having more patients listed at their practice and providing a wider range of services. Overall, our findings provide evidence of the benefits and improved outcomes of FP trainers and training practices. The benchmarks set by the FP-trainers and training practices reported here could be used as the basis for Continuous Quality Improvement in the profession within both training and non-training practices.

Our findings show that FP trainers and their host practices offer a wider range of services with more teamwork, more quality management, and the trainers report experiencing less job stress than non-trainer FPs. Moreover, hosting a FP trainer in a practice may have positive spin offs on and for other colleagues. All this may encourage more individual FPs and their host practice to become trainer and training practice respectively, as our study confirms that there are intrinsic benefits to FPs and practices to training status. However, for training and non-training settings alike, multiple quality assessments within continuous quality systems such as ongoing accreditation, provide detailed feedback on practice organization and care and highlights quality deficits that need to be addressed. There is a need for multiple sources of data showing variation between FPs and practices that offers an extra opportunity for quality improvement for those undertaking the training of FP trainees.

Since 2005, FPs had the opportunity to voluntarily participate in the Dutch FP accreditation program. They receive information about the accreditation program including a questionnaire on expectations. Preparing for the first visit may take about one year.FPs gather data about their practice management and patient care followed by a pre-audit of a trained observer. Comparison with benchmarks of other FPs and practices helps to identify substandard performance stimulating FPs to make improvement plans.The first audit is carried out after delivering these plans to confirm adequate participation and to grant accreditation. It is the start of a three-year accreditation program and an assessor does the follow-up of the plans. The prolongation of the accreditation depends on having met the objectives of the improvement plans.The measurement in the accreditation program uses previously validated instruments such as VIP [11], clinical performance [12], and Europep [13]. The measures have been based on questionnaires for FPs and practice nurses, on structured observation by trained observers and on patient questionnaires as well as on patient data from electronic medical records.