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A dialogue: how to run an educational meeting for GPs Paul Morrish,1 Jim Morison2 1

Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK 2 Severn Deanery, Deanery House, Hambrook, Bristol, UK Correspondence to Dr Paul Morrish, Department of Neurology, Gloucestershire Royal Hospital, Gloucester, GL1 3NN, UK; [email protected] Published Online First 8 June 2013

To cite: Morrish P, Morison J. Pract Neurol 2013;13: 322–325.

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Neurologists frequently teach general practitioners (GPs) and write articles for GP journals. Yet reports on UK neurological care often comment on GPs’ delay in diagnosis and lack of understanding of neurological conditions.1 To address this conundrum, I discuss with Dr Jim Morison—a colleague in GP education— how we might improve GP education in neurology. PM: What can neurologists do to help GPs to manage neurological conditions and address the communication gap between specialists and generalists? JM: Patients undoubtedly benefit if their GP has a better understanding of their neurological symptoms and illnesses. However, the traditional large lecture (where pearls are cast by haughty specialists to an audience of generalists salivating with anticipation) may not be the best way to achieve this. Getting an educational message across well to GPs requires more thought and planning…. PM: So what might be better? JM: Meetings of small groups of local doctors discussing local experiences with local specialists make the learning relevant to the local needs of the doctors and of the service—and more likely produces genuine and sustained behaviour change. PM: Neurologists could then talk about what they do in 2013 (rather than when the GP was at medical school), what they want and do not want to be referred, and what might be achieved from an appointment. JM; Remember that education is not a one way process, and neurologists could also learn from experienced GPs—how, for example, to manage medically unexplained symptoms or to judge the right time to investigate. They could also learn how doctors in primary care can manage neurological symptoms and illness. PM: It has been said that GPs may not want to learn about neurology: rising referral and admission rates1 hint that

there is already some handover of neurology—from primary to secondary care. JM: For GPs, the rising numbers of patients with neurological symptoms— and the increase in performance assessment and pressures not to refer—mean that avoiding such common medical presentations and problems is not an option, if it ever was. There will certainly be GPs who want to learn. PM: So how does one go about it? JM: First by acknowledging that neither GPs nor neurologists can run a meeting without the other. The co-organisers must consider the educational and not-so-obviously-educational components. The best way would be to ask GPs individually what they want to learn but that is difficult in advance. Instead, you can sketch a rough plan (figure 1) and be prepared to be flexible. On the day, the organisers can use ‘group facilitation’ to ‘identify learning needs’ ( please excuse the educ-speak but learning the language helps to play the game). This is not complex but needs delicacy. You could ask the audience what they would like to learn, or simply ask, ‘Why are you here?’, knowing that some might leave but most will engage. You could try an ‘icebreaker’, for example, a short quiz or ask their first thoughts when they hear the word ‘neurologist’ (figure 2). They could pair up and talk neurology to each other. GPs love talking about their patients and subtle steering will get them discussing their own memorable encounters. It is good because you do not have to do the work and it gets them thinking about neurology in their everyday world. They might then share stories with the group and it should be possible to theme together the points raised to develop a good range of topics. PM: One game—‘What’s in the Box?’—works well. The organisers place a box in the room, and the audience puts questions into it. At the end of the day,

Morrish P, et al. Pract Neurol 2013;13:322–325. doi:10.1136/practneurol-2013-000611

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Figure 1

A typical menu.

Figure 2 Ask the audience to say aloud what they think when they hear the word ‘neurologist’. Photo source: www. cartoonstock.com


we open the box and air the questions that everyone might be interested in (but were too afraid to ask). JM: That takes some courage, but the box rarely contains googlies. It is also a way to check that the day’s content has been on target. PM: Educators tell us that we must meet the learner at point A to take them to point B. But point A can range from a GP who missed his or her medical school neurology to the post-MRCP GP neurology expert. JM: So helping them to find their point A is really important. Did I mention ‘identifying learning needs’? Adults also learn best when they relate their learning to their own world. Putting this into context, the ‘external specialist resource’—the neurologist—must take care, as they may have little clue what a GP’s world is like. The educ-speak word here is ‘experiential’ learning. PM: This all sounds easy but the audience may stay quiet or might want to cover something you have not planned or prepared. JM: Another option is to tell them what you did in clinic yesterday, with examples up your sleeve to illustrate points. ‘GP referral case presentations’ resonate with the audience immediately: a few letters will prompt discussion of how you assessed and managed each patient. Again, we are being experiential, relating the education to the everyday world we work in. Most GPs do not enjoy being put on the spot, so encouraging group discussion is more rewarding than targeting closed questions to likely looking individuals in the audience. If you are thinking, ‘How can anyone be prepared for everything that could be asked? ’ then be reassured: the key is that what they want to know will be meat and drink to you, the sort of information you take for granted. And, in the middle of the day’s educational sandwich, you can slip in things that you want to tell them. PM: In my experience, GPs like to discuss the management of common neurological symptoms (headache, weakness, dizziness) and illnesses (migraine, stroke, dementia) but also how to recognise what, in their world, is a rare illness. A GP sees one new case of multiple sclerosis every 3 years, so how do they not miss it among the other 9000 consultations over that time? JM: Well, when you see a patient with a numb or weak leg, how do you establish whether it is something or nothing? They could also ask about pain management, rehabilitation or bladder, bowel and spasticity management. PM: GPs sometimes ask about the patients they have managed, and whether they did the right thing. JM: They might also ask how you examine the nervous system, and how to take safe short-cuts (do not forget that a GP consultation is probably 10 min maximum). 323

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Figure 3

Feedback can be a mixed blessing.

PM: So what is the right number to teach? JM: Most GPs learnt their craft through a combination of lectures and small group learning. Each has pros and cons, so you could offer both. But, to reiterate, the larger the lecture theatre and the more didactic the lecture, the less likely that individual GPs will learn what they feel they need to learn. If you have the right ratio of teachers to learners, then teaching small groups on common neurological problems works well—a GP facilitates and the neurologist acts as a resource. Small group teaching works best with up to about 20 participants. You can split a bigger audience into manageably-sized chunks and seek a reporter from each. The reporters usually identify themselves—after a few shifty glances. The ones who step forward can become useful allies as the session develops. An open discussion with the audience in these situations is immensely valuable and can break the barrier between specialist and generalist—the audience can identify with the problems being discussed, because a peer raised them. PM: How much time can they give? JM: GPs often manage a half-day, and occasionally a whole day. Alongside all the other things a GP must learn, one day in neurology every few years has to be enough. PM: GPs outnumber neurologists by 100 to 1: so if a neurologist spends one day once a year teaching 33 GPs, they could reach them all in 3 years. Neurophysiologists and rehabilitationists, specialist nurses and neurology registrars can go down well. Expert patients and neurology charities help too, but beware those with axes to grind. Outside speakers provide variety and expertise but GPs do not care if the speaker is head of the Association of British Neurologists or Medical Research Council if they are unapproachable, pontificate or delay coffee. Videos and audioclips are good when they work. What else makes a good day? JM: A nice place and enough time to meet and exchange views with colleagues, easy parking and a small queue for a nice lunch. PM: How do the finances work? JM: There is usually a fee to attend a meeting and also the cost of the work in the practice while away. 324

For a top price (£100), GPs expect a well-run day, a nice venue, a small enough audience for them to ask questions and a handout to take home. Conference venues charge between £5 and £50 per delegate for conference facilities, lunch and tea and coffee. You may need to pay some speakers. If pharmaceutical companies help to fund the meeting, be alert to the rules.2 PM: Is a certificate of attendance necessary? JM: There is no mandatory requirement to have the session externally approved. The Royal College of General Practitioners has an ‘Accreditation of Educational Activities’ scheme3 but accreditation fees add considerably to your costs. There are informal schemes such as the UK Severn Deanery kitemaking4 and you could always run off a few certificates yourself. The certificate mentality demonstrates a ‘bum on a seat’ but not necessarily education. Most GPs record their own learning, often in the form of notes—the buzz phrase is ‘reflective notes’—and these provide evidence in appraisal of a GP’s continuing professional development activity. PM: How do neurologists make their educational session better than other specialties and educational providers? JM: Your advantage is that audience will know local neurologists’ names and reputations, and their subject induces fear and interest. However, the competitors have large advertising budgets, full-time skilled educators, handouts, books of information and smart-phone apps. PM: How do we know it has been successful? JM: Be sure to finish with a summary and feedback session to cement the main messages, and what has been good (or not). You will have entertained and introduced some neurology to a receptive audience. They may now know what they did not know they did not know, and they can put the day’s learning into the context of their professional lives. They have networked with colleagues, engaged with specialists and hopefully had an enjoyable and useful day (figure 3). If all has gone well, they might even go out whistling (figure 4). The neurologist will also have promoted their specialty and department, maybe thrown in a bit of hot-off-the-press neurology, and met some names from their referral letters.


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Figure 4

How not to do it.

PM: It has been said before5 but yes, we really must get out more …. An explanation, for overseas readers, of the relationship between GPs and UK National Health Service (NHS) neurologists: To see a specialist in the UK, patients must first see their GP; what a UK neurologist does in outpatients is largely determined by the referral practice of local GPs. A GP might conduct around 3000 consultations per year, of which 4.4% will be headache.6 GPs refer around 4% of those patients to a neurologist. There are around 100 GPs to each neurologist. Hence, if each GP doubled their referral rate of patients with headache, each neurologist would see an additional 500 new patients each year. The current financial climate means that expansion of neurology is limited and GPs are encouraged to avoid referral. At the same time, the English NHS has undergone a major organisational change. Some GPs have been appointed to act as commissioners, whose role is to determine where and how much secondary care neurology they need and whether direct access to tests and use of qualified alternative providers—such as specialist nurses, specialist GPs and other medical specialists— give better value. Hence, the recently started English commissioning process offers opportunities and threats to neurology. There is a good summary of the rationale


and challenges of these NHS reforms, which is free to be downloaded.7 Contributors PM wrote a lot of it and JM contributed as in the text. Competing interests JM is a GP, GP trainer and Programme Director of a GP training scheme. Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Greg Rogers, Kent, UK, and Jeremy Gittins, London, UK.

REFERENCES 1 http://www.nao.org.uk/publications/1012/ neurological_conditions.aspx (accessed Mar 2013). 2 Association of the British Pharmaceutical Industry. Code of practice for the pharmaceutical industry. ABPI, 2012. 3 http://www.rcgp.org.uk/revalidation-and-cpd/ rcgp-educational-accreditation.aspx 4 http://www.primarycare.severndeanery.nhs.uk/training/ qualified-gps/quality-assurance-and-kitemarking/ 5 Warlow C, Allen C, Venables G. Bringing neurology to the people. Pract Neurol 2008;8:208–10. 6 Latinovic R, Gulliford M, Ridsdale L. Headache and migraine in primary care: consultation, prescription and referral rates in a large population. J Neurol Neurosurg Psychiatry 2006;77: 385–7 7 Timmins N. http://www.kingsfund.org.uk/sites/files/kf/field/ field_publication_file/never-again-story-health-social-carenicholas-timmins-jul12.pdf

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