North Dublin City GP Training Programme  

 

 

This vision and mission drive everything on the NDCGP and are constantly referred to at all decision fora. The scheme achieves its mission in all facets of the scheme:

• The Curriculum:

  • Social Medicine Module

  • Self Care Module.

  • Change Management Module

  • Research Module

  • Arts Module

• The Hospital Posts

• The GP Training Practices

• Special Interest Posts

• Vision & Mission Committee

• Post Scheme Mentoring & CME

• GP Practices in Areas of Deprivation

 

The Curriculum:

As with all GP training schemes the Curriculum focuses on training GPs to provide quality primary care. However there are several modules that focus on the Vision and Mission of the Scheme.

 

Social Medicine Module

This module focuses on transferring the necessary knowledge required to provide primary care in areas of deprivation and with marginalised groups. In the first year trainees are taught about social constructionism, labelling, stigma and discrimination. At the end of first year they are tasked with creating a Deconstruction Video Blog where they take a medical subject and deconstruct it on video and post it online. The aim of this is to teach them the art of deconstruction that will allow them to deconstruct stigma, prejudice and also health fallacies. In their second and third years they focus on information on health inequalities and on the concept of Primary Healthcare (as opposed to Primary Care) which seeks to explore the wider community response to health needs. This includes site visits to community services in the North City in areas of deprivation and working with Youth at risk / drug misusers and homeless. In their GP practice in third year they have the option of doing a health needs and/or health service mapping in their GP practice area instead of an audit. At the end of second year they have to apply health inequity theories to cases they have encountered in the Social Medicine Essay.  In their fourth year they learn about the health and service utilization of marginalised populations including homeless, drug users, migrants and travellers.

 

Self Care Module

Early on the scheme adopted an emphasis on promoting self-care. This was based on the belief that providing services in areas of deprivation and to marginalised groups is stressful and if trainees do not learn how to self-care, once they become practitioners they could face compassion fatigue and  burnout. This module entails looking at self-care and engaging in a Mindfulness Based Stress Reduction course and a Balint group.

 

Change Management Module

The scheme seeks to create a capacity within primary care in North Dublin to address health inequities. This entails having the skills to change mindsets and methods of delivering healthcare in these areas. Change management provides skills to trainees to achieve their aim to improve practice and health in these areas,

 

Research Module

Research is a necessary component of the General Practice National Curriculum. NDCGP ensures that trainees focus either primarily on health inequity (e.g. research on drug overdose) or if they have a particular interest area they want to research, ensure that health inequities are considered in the research proposal (e.g. research on attitudes to influenza vaccinations in pregnant women included identifying the effect of socioeconomic status).

 

Arts Module

The scheme has an arts module which is not a set in stone module but is delivered by trainees and programme directors attending one arts event per six weeks. The Arts Officer looks out for arts events that address health inequities e.g. one of the most powerful sessions we ran on health inequity centred round a play The Boys from Foley Street which detailed the effect of the heroin epidemic in Dublin in the 1980s. We find that the registrars have been taught through multiple case conferences to remain emotionless and stoic when listening to heartrending stories cloaked in the garb of medical parlance. Those same registrars become emotional and tearful in front of a powerful theatrical or film viewing. The change in setting allows them to become human and from an educationalist perspective allows us to explore social issues with more emotionally engaged learners.

 

The Hospital Posts

The scheme sought out hospitals which were located in catchment areas with areas of blanket deprivation. Hospital consultants were briefed on the schemes Vision and Mission and were asked to encourage trainees to consider the social determinants of health when reporting on ward rounds or case meetings.

 

The GP Training Practices

Likewise the scheme focussed on recruiting GP trainers from areas of deprivation. The programme directing team worked with the Health Service Executive to identify areas of deprivation with poor GP to patient ratios and advertised for trainers in those areas specifically. GP lists were also screened to ensure that they were open to all marginalised groups. All trainers had to be qualified to prescribe methadone and have methadone patients in treatment.

 

Special Interest Posts with Marginalised Populations

The Special Interest Posts are how we train GPs to work with marginalised populations. They are a critical element of the GP Training Programme. In fourth year the GP registrars spend one day a week working in special interest posts with marginalised populations. GP trainers agreed to release their registrars for one day a week in fourth year so as to allow the registrar to be placed in a health service that provided care to the marginalised. These placements were Addiction Services; Homeless Health Services and Community Marginalised (including Prisons and Migrants who do not have access to healthcare. The theoretical model underpinning these placements was Alports Contact Theory whereby ‘real’ engaged contact between registrars and marginalised groups would improve knowledge of each other and breakdown stereotypes and stigma.

 

As part of these posts the registrars have to conduct a qualitative research type interview. The aim of this is not to introduce them to qualitative research but to get them perceiving their patients outside the medical gaze.

 

The following video outlines the effect of these placements:

https://vimeo.com/141778095

 

Vision & Mission Committee

It was decided two years ago to appoint a Vision and Mission Committee made of trainees from each year and a Programme Directing Team member. Their role was to ensure that the Vision and Mission remained a living and organic entity and not a few paragraphs in a scheme prospectus. In their first year the V&M committee decided that they wanted to do something active to ensure people understood the Vision and Mission. Some of them had attended an Internaional Street Medicine Conference in 2014 and had been so inspired that they decided they wanted to host an Irish Street Medicine Symposium. This was so successful that several homeless agencies asked for the scheme to conduct the event annually.  In 2015 they have decided they will provide support to a new Cold Weather Initiative hostel of 120 homeless people which will include running clinics; vaccination programmes; health screening; naloxone administration and resuscitation training.

 

Post Scheme Mentoring & CME

As the vision and mission of the scheme goes beyond when training is finished we want to maintain contact with our graduates so as to maintain their energy and enthusiasm to provide primary healthcare to areas of deprivation and marginalised populations. To this end we have launched a Post scheme mentoring and Continuing Medical Education programme which is provided by Programme Directors.

 

GP Practices in Areas of Deprivation

When the first cohort of GP registrars graduated it soon became apparent that, although  they had a desire to work in areas of deprivation, because there were few GPs working in these areas there were few opportunities to become engaged in practice. Setting up practice in an area of deprivation is a daunting task. The scheme has close links with Safetynet Primary Care Services who provide primary care services to marginalised populations (including homeless; migrants; Roma and drug users) throughout Ireland. The founder of the NDCGP also founded Safetynet. Safetynet has developed a new initiative were it has been promised philanthropic funding to set up practices in areas of deprivation. The graduates of NDCGP are eager to work in these practices. Safetynet will manage and run the practices taking the financial burden during the lean years and recouping their investment when the practice becomes profitable. Safetynet will then re-invest the funds in practices in other areas of deprivation. After five years Safetynet will offer its doctors the opportunity to buy out the practice or continue as Safetynet employees.

 

When this scheme was first proposed in 2009 many people advised that it should not advertise that it was going to train GPs to work in areas of deprivation or with marginalised groups on the basis that this would deter people applying. Ironically, it has had the most amount of applicants of any scheme since its launch. This is testament to the hunger of young doctors to make a difference and a rebuke to us older doctors who have lost faith in the compassion of youth.

 

Impact of the Scheme

It is too early to evaluate the effect of this programme. We are monitoring where graduates end up in their future careers. What we have achieved though is that the Irish College of General Practitioners has instituted a Social Medicine Module in the National Curriculum; the capacity of specialised services for homeless people, prison populations and drug treatment centres have expanded due to GP trainees working in areas of deprivation; the number of GP trainees in practices in areas of deprivation has improved significantly in Dublin; one third of GP trainees who qualify for methadone prescribing come from our scheme; a new health service for Non Habitual Residence Clause Migrants has been developed and recognised by the Health Service Executive as part of the response to healthcare for undocumented migrants; and the Mobile Health Clinic for Homeless People (staffed by GP trainees both in the NDCGP and other schemes with Safetynet) has become recognised as part of the national response to addressing the health needs of homeless people.

 

[1]   Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in          Los Angeles. Am J Public Health. 1997 Feb Feb;87(2):217-20.

[2]   Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J                  Public Health. 2010 Jul;100(7):1326-33.

 

Contribution by Dr Austin O’Carroll (NDCGP Director) 19.12.15. For further information contact: northdublincitygp@ucd.ie