Skip to main content

Table 4 Details of structure and content of pilot GP training sessions

From: Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice

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