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Abstract
Objectives The implementation of outpatient training in primary care settings is an essential part of residency training for general practitioner (GP) residents. However, limited research exists on their experiences and perceptions of this training. This study aimed to explore the experiences and perceptions of GP residents regarding outpatient training in primary care settings in China and provide insights and recommendations to enhance training quality.
Design A qualitative descriptive study employing in-depth interviews.
Setting Two community healthcare centres (CHCs) that implement outpatient training programmes for GP residents in Zhejiang Province, China.
Participants In total, 20 GP residents affiliated with 14 CHCs and two hospitals across Zhejiang Province and Guizhou Province who had completed outpatient training in either CHC for over 1 month.
Results Of the 20 participants in this study, 11 (55%) were women, and the mean age was 28 years. GP residents completed the process of consultation, physical examination and therapy independently; subsequently, the community preceptors provided feedback based on their clinical performance and modelled their clinical skills. The benefits perceived by GP residents included improved clinical skills and confidence in practice, and they learned approaches to maintaining good relationships with patients. They preferred dealing with complex cases, discussions with peers and the indirect supervision of community preceptors in the training session. Residents recommended that measures be taken to improve the training quality regarding patient selection and recruitment, clinical skills in the training session, and assessment of clinical performance.
Conclusions The outpatient training in primary care settings provides constructive opportunities for GP residents to improve their professional competencies. Although the current training sessions and the abilities of community preceptors largely satisfy the needs of GP residents, further research is needed to evaluate the effectiveness of training and explore approaches to improve its quality.
- primary care
- qualitative research
- medical education & training
Data availability statement
Data are available upon reasonable request. The transcripts used during the current study are available from the corresponding author upon reasonable request (zhijiexu@zju.edu.cn).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This is the first qualitative study exploring general practitioner (GP) residents’ experiences and perceptions of outpatient training in primary care settings in China.
The researchers conducted semi-structured in-depth interviews with participants who were selected in conjunction with the process of data analysis.
The study recruited GP residents from a single teaching hospital and the results may not reflect the wider population.
One of the interviewers had prior experience as a trainer in the teaching hospital and worked with a few participants, which might have influenced the results.
Introduction
Outpatient training in primary care settings is a critical component of general practitioner (GP) residency training globally. It equips GP residents with essential clinical skills in real-world patient care, communication and inter-professional collaboration. Despite the growing importance of outpatient care, GP residency training focuses primarily on inpatient settings, leaving many graduates unprepared for careers in outpatient care.1 Current training models limit GP residents’ exposure to outpatient settings, which can negatively affect their confidence, stress levels and personal fulfilment in providing high-quality care.2 For example, GP residents in the USA spent approximately one-third of their training time in ambulatory settings, and measures to close this gap are needed to align training with future practice.3
The challenges of GP resident training in China are broadly similar to those in other countries, but with a few complexities. Since 2009, China has implemented multiple GP training programmes taking a variety of different approaches; however, these programmes lack uniform educational blueprints and core competencies, leading to inconsistent GP competencies and decreased public trust.4 5 The medical education system for GPs in China comprises five different training programmes, each with its own duration and objectives. The most highly regarded programme is the ‘5+3’ model, which involves 5 years of medical school followed by a 3 years of GP residency. On completion of the 5-year undergraduate education, doctors have the option to independently apply for a GP residency at standardised training bases or to enter into labour contracts with employing institutions such as hospitals or community healthcare centres (CHCs), which may then send GPs to standardised GP training bases for further training.6 The certification of a standardised GP training base, which is endorsed by the Chinese Medical Association, is inclusive of both hospitals and CHCs.7 During the 3-year GP training, residents engage in a combination of in-hospital and staged community training. This comprehensive framework allows for the development of diverse pathways to produce highly skilled GPs.
In China, GP residency rotations span 3 years, during which residents spend only two periods of 1 month and one period of 5 months in community healthcare training bases (ie, CHCs), with a primary focus on outpatient training.7 GP residents receive training in primary care settings led by experienced GPs in the community healthcare training bases, known as community preceptors. Preceptor’s teaching is supervised by both the community healthcare training base and the standardised GP training base (ie, the teaching hospital).8 Given their relatively low educational background and inadequate training in teaching skills, community preceptors exhibit limited teaching proficiency. Further, the proportion of community GPs who have been officially certified as qualified preceptors is relatively low because national or provincial training and certification have only been introduced in recent decades.9 The short and fragmented nature of residency rotations in primary care settings and the shortage of qualified community GP preceptors further contribute to the challenge of effectively training GPs for primary care settings.
Investigating the experiences of GP residents is crucial to gain a comprehensive understanding of the current situation and to facilitate potential improvements in outpatient training. By collecting GP residents’ perceptions, tailored programmes can be devised to address their specific requirements, thus ensuring comprehensive learning and enhancing patient care outcomes. Insights from GP residents can help identify best practices and support ongoing evaluation, leading to improved supervision, mentoring, and training outcomes and ultimately preparing them to provide high-quality primary care.10–12 Previous research on the implementation of outpatient training in primary care settings in China has reported, for example, that community preceptors often lack proper teaching skills and resources, and that overcrowded training environments further limit the effectiveness of standardised outpatient training.13 14 However, Chinese GP residents’ perceptions of these problems during outpatient training have not been well studied.
Although a few studies have noted the beneficial impact of outpatient training in primary care settings in China, with GP residents expressing high satisfaction with their community preceptors and recognising that the training considerably improved their clinical expertise and communication abilities,15 16 there is a paucity of data on the overall impact of outpatient training on GP residents’ experiences and perceptions. A qualitative approach enables researchers to capture the intricate nuances of training experiences and offers a comprehensive understanding of the process, resulting in an enhanced training system and strategies for GP residents and community preceptors.17
This study explored GP residents’ experiences and perceptions of outpatient training in primary care settings in China qualitatively. We aimed to gain a contextualised understanding of the GP resident outpatient training process, as well as the factors that may influence the effectiveness of such training, ultimately informing new strategies for developing high-quality training programmes.
Methods
We employed qualitative interpretive description as the principal methodological approach because of its flexibility in addressing intricate experiential inquiries while considering pragmatic outcomes.18 This approach aligns with our objective of examining GP residents’ experiences and perceptions of outpatient training in primary care settings. Our primary focus was not on theory construction, but rather on providing a comprehensive understanding of the training GP residents underwent in addition to their perceptions of the training, in order to provide recommendations for enhancing training quality.
This study adhered to the Consolidated Criteria for Reporting Qualitative Research guidelines in order to maintain rigorous reporting standards for qualitative research.19 ,20
Setting and study population
A purposive sampling strategy was used, with invitations extended personally or through a mobile application (DingTalk). GP residents undergoing training at Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU) were chosen from 14 CHCs and 2 hospitals across Zhejiang and Guizhou Provinces to ensure maximum variation in age, educational background, practice duration and institutional affiliation. The eligibility criteria included a minimum of 2 years of training experience at SAHZU and at least 1 month of outpatient training in either the Xiaoying District CHC or Nanxing District CHC. The recruitment process was conducted iteratively in conjunction with the data analysis, and the sample size was established based on data saturation. Interview scheduling was terminated when the accumulation of additional interview data had minimal impact on the established codebook and did not reveal any more novel patterns or themes. Three residents declined to participate due to scheduling conflicts. Participants were familiar with their interviewers, with approximately one-third having worked with one of them (LW) in the past. Participation in the study was voluntary, and no compensation was offered to the residents. Repeat interviews were not conducted.
Interview guide
The interview guide was developed through a comprehensive review of the relevant literature, followed by pilot interviews with two GP residents and extensive discussions among all authors. To further enhance the rigour of the interview guide, experts in the fields of primary care and medical education were consulted, and their feedback and suggestions were incorporated into the final version of the guide. The probing questions were iteratively refined to align with the data analysis process. The interview questions broadly addressed the nature of the outpatient training received by GP residents in primary care settings, focusing on three key domains: (1) participants’ experiences during the training process, (2) participants’ perceptions of the training and (3) recommendations for improving the quality of the training (see online supplemental file 1). Beyond the prepared questions, participants were encouraged to share any additional comments they deemed relevant to their interviews.
Supplemental material
Data collection
From 5 August to 30 October 2022, two interviewers, one female (LW) and one male (ZX), both of whom were GPs with expertise in qualitative research methods, independently conducted semi-structured in-depth interviews. The interviewers first contacted the participants via telephone to coordinate a mutually agreeable interview time. Two days before the scheduled interview, the participants received an interview outline, allowing them to familiarise themselves with the topics to be discussed. At the appointed time, the interviewers and participants engaged in an in-depth interview in a quiet and private setting, ensuring optimal conditions for open and candid dialogue.
Before conducting the interviews, a comprehensive explanation of the study’s objectives, methodology and potential implications was provided to all participants. Subsequently, they were given the opportunity to address any concerns or inquiries. Once their understanding was confirmed, the participants voluntarily provided written informed consent, confirming their agreement to participate in the study and acknowledging the potential use of their anonymised data for academic purposes. Personal data were collected from each participant to establish a comprehensive understanding of their background and context; however, measures were taken to minimise the risk of accidental information disclosure.
Throughout the face-to-face interview process, the interviewers inquired about the participants’ experiences and perceptions regarding outpatient training received in primary care settings. Interviewers adopted a flexible approach, adjusting the sequence and manner of questioning according to the individual circumstances of each participant. To elicit more comprehensive and nuanced information, probing questions such as ‘Why do you hold this opinion?’ and ‘Can you provide an example?’ were used. The interviewers maintained a respectful stance, refraining from judgement and avoiding any encouragement or intervention to ensure an unbiased and open exchange of perspectives.
During the interviews, a recording device (IFlytek SR501) was employed to capture the entire interview, with the duration of each interview kept within a 30–50 min timeframe. The interviewers made field notes on key information whenever necessary that served as an additional source of data to complement the audio recordings and transcripts of the interviews by capturing non-verbal cues, contextual factors and other pertinent observations.21 Participants were assigned numerical codes, and all personal identifiers were removed from the transcripts and other study documents to ensure anonymity while maintaining the integrity of the data collection process.
Data processing and analysis
The interview data were transcribed verbatim within 24 hours of each interview, and the transcripts were meticulously checked for accuracy against the corresponding audio recordings. Two researchers (LW and YT), both with extensive training in qualitative data analysis, adopted a line-by-line approach to code the transcripts separately. During this process, the two researchers generated initial open codes, which were then discussed and refined, ultimately leading to the development of a preliminary codebook. Subsequently, the two researchers analysed the coded data across transcripts to identify themes and subthemes regarding GP residents’ experiences and perceptions of outpatient training in primary care settings. The constant comparative method was used to compare and expand existing categories while identifying novel categories until no further subcategories emerged.22 The data analysis was conducted between August 2022 and January 2023 using the MAXQDA 2020 (VERBI Software, Berlin) software. Frequent team meetings were held to review and discuss the coding and analysis process and to enhance the rigour and reliability of the study.
Data saturation was attained after the completion of 17 interviews, after which three additional residents were interviewed to ensure comprehensive data coverage. In instances in which discrepancies emerged in the data analysis, a third investigator (ZX) was consulted to facilitate a resolution. The transcripts were not returned to the participants; however, five interviewees were provided with the results of the data analysis (ie, the main findings of the preliminary manuscript, a table comprised themes, subthemes, interpretations and representative quotes) to review and offer feedback on, thereby indicating their consent and collaboration (see online supplemental file 2).
Supplemental material
Patient and public involvement
In this qualitative study on the experiences and perceptions of GP residents in outpatient training, all authors and participants, including the primary researcher who conducted the interviews, are practicing GPs. Our research questions centred around GP residents’ outpatient training, requiring direct engagement with the GP residents themselves. We aimed to capture their experiences to inform improvements in training programmes in primary care settings. Therefore, patient and public involvement was not included in this study.
Results
In total, 20 GP residents (consisting of five second-year residents and 15 third-year residents) were interviewed for a mean of 42.7 min (range: 35–49 min). Of the participants, 9 were male and 11 were female, with a median age of 28 years (age range: 25–35 years). The distribution of residents who received outpatient training at Xiaoying and Nanxing CHCs was similar. Most participants (85%) were affiliated with CHCs before they received GP residency training, and the remaining were affiliated with comprehensive hospitals.
Experiences
Patient characteristics
The community preceptors purposefully recruited patients for this outpatient training programme. They had prior familiarity with the patients’ medical conditions before their encounters in the outpatient setting. A significant proportion of patients seen by the GP residents had multiple stable chronic conditions, with diabetes and hypertension being the most prevalent. Conversely, a minority of their patients exhibited symptoms but had not been diagnosed with any specific disease. Participants acknowledged that both types of patients provided unique opportunities to enhance their clinical skills in distinct ways.
So, the patients we worked with had a range of chronic conditions like peptic ulcers, hypertension, diabetes, and coronary heart disease. These are pretty common conditions, so it was a great learning opportunity for me to develop my skills in managing chronic diseases … I get a kick out of working with new patients who have unusual symptoms that haven’t been diagnosed yet. It was kind of like being a detective, trying to figure out what was going on and how we could help them. (Participant 9, male, PGY-3)
Many patients attending clinics were well prepared, providing detailed medical histories during consultations and frequently brought their previous clinical reports with them. Some participants stated that patients displayed a high degree of patience throughout the training process, which facilitated effective face-to-face communication, promoted a supportive learning environment and fostered greater empathy among GP residents.
When I first started out, I was a bit worried about how patients might perceive us as young doctors. But as it turned out, I found the patients to be incredibly friendly and cooperative. Even when I asked a lot of questions or repeated myself, they were always patient and willing to help me learn. (Participant 6, male, PGY-3)
Training process
During the course of outpatient training, GP residents were required to obtain detailed information regarding patient complaints and other health-related issues. In addition, they were expected to inquire about the patients’ emotional well-being, economic status and family support. Targeted physical examinations were also performed based on patients’ specific needs. The collected information was then integrated and analysed by residents to formulate diagnoses and treatment plans. The residents were also expected to document the patients’ medical records in the SOAP format (ie, subjective, objective, assessment and plan) using a standardised manual.
The preceptors required us to write medical records immediately after each patient consultation in the clinic. It was a challenging task, as we had to document the patient’s complaints, clinical examinations, diagnosis, and treatment plan in just 15 minutes. This kind of record contains a lot of information, and it took a lot of practice to complete it within the given time limit. (Participant 19, male, PGY-3)
The GP residents were instructed on how to make appropriate referrals when necessary. However, a minority of the participants admitted that they might have overlooked the need for referrals unless prompted by community preceptors. Some participants expressed uncertainty regarding the indications for referral because of their limited experience in determining whether a patient should visit the emergency room or seek specialist care.
I found it challenging to decide when to refer a patient to a specialist or the emergency room. It’s particularly difficult when dealing with patients with multiple conditions, such as those with diabetes who experience persistent chest tightness or those taking statins who complain of unexplained muscle soreness. It’s a tricky balancing act. I want to make sure that I am making the right decisions for my patients. (Participant 12, female, PGY-3)
Most GP residents underscored the significance of effective communication regarding health education, with particular emphasis on lifestyle modifications. Several participants revealed that they often advise patients with metabolic disorders to lose weight and engage in regular exercise. In addition, some have employed visual aids such as diagrams and models of food and vessels to better convey their recommendations. Nevertheless, the participants acknowledged the difficulties encountered when offering advice on medication use, with many admitting that resolving medication-related issues was particularly challenging.
I am good at taking medical history and performing physical examinations, and I feel confident in helping patients make positive lifestyle changes. But when it comes to medication therapy, I find it difficult to create a detailed management plan … I often only provided rough plans and general advice … I need more training and guidance to create more professional plans. (Participant 13, female, PGY-2)
Community preceptor guidance
During GP residents’ consultation process, community preceptors typically sit alongside GP residents, closely observing their performance. This comprehensive observation encompasses the evaluation of multiple aspects, such as non-verbal and verbal communication skills, as well as their ability to make clinical decisions effectively. They noted the residents’ interactions with patients and provided constructive feedback for improvement. In general, preceptors refrained from interrupting unless the residents requested assistance or made significant errors that could potentially harm the patient.
Following a consultation, community preceptors typically pointed out any missing details in the medical history or physical examination, explained the treatment plan to the patient and provided additional instructions. Many participants mentioned that they appreciated the preceptors for escorting patients out of the clinic and expressed gratitude for their participation. Moreover, several residents reported having received instructions from preceptors to pay close attention to the family support of patients, particularly older adults.
When I was seeing the patient, the preceptor came over and pointed out some details that I missed. He focused on the treatment plan and highlighted what the patient should remember in their lifestyle. Then, he explained everything to the patient in a way that they could understand. It was really helpful. He even reminded the patient to call back if she forgot any of the advice. (Participant 17, male, PGY-2)
At the conclusion of each training session, community preceptors provide regular feedback to GP residents on their clinical performance. Typically, the feedback began with positive remarks highlighting the areas where residents excelled, before addressing any weakness that required improvement. The preceptors then offered suggestions for practices aimed at enhancing residents’ clinical skills. Additionally, the preceptors provided feedback on residents’ written case files, including corrections and commentaries. However, a few participants noted that feedback from preceptors was occasionally too general and failed to provide adequate guidance for improvement.
When the preceptors checked our medical records, they used a red pen to correct any mistakes or missing information. They would then give some brief comments on the records and suggested ways to improve them. For example, they pointed out the importance of identifying modifiable and non-modifiable risk factors for certain diseases. (Participant 3, female, PGY-3)
I felt like the preceptor didn’t give me enough practical advice. Sometimes, they would just go through the process and give general feedback that wasn’t really useful for me to improve. (Participant 20, male, PGY-3)
Perceptions
Perceived benefits
The participants unanimously agreed that the outpatient training created a good environment for them to apply what they had learned in practice. The GP residents saw real patients, dealt with their medical problems mainly by themselves, and were thus able to use the knowledge and skills they had learned to solve the patients’ health problems. They believed that this training gave them the opportunity to constantly practice and accumulate clinical experience.
The opportunity to see a patient by ourselves was relatively lacking when we were trained in the hospitals, but here we have the opportunity to experience how to deal with patients in the primary care clinics. The training is always resident-centered. You are expected to have your own ideas, make decisions, and communicate with patients. (Participant 20, male, PGY-3)
The participants also agreed that the outpatient training helped them discover and overcome shortcomings in their performance. The differences observed between the preceptors’ modelling and their own performance, and the shortcomings pointed out by the preceptors during feedback, made it clear to residents what they needed to improve. This aroused their enthusiasm for participating in training as well as for finding ways to improve themselves. Some participants expressed full confidence in their ability to deal with patients after the training, whereas others said that they had learned how to help patients, which increased their sense of responsibility.
At the beginning I was a little nervous, but later on, I felt like I could handle it, like I had some experience and confidence. After several times of training, I know how to answer their questions, which examinations need to be done, and what urgently needs to be done. I have a plan for the patient, and I can solve some of their problems. (Participant 12, female, PGY-3)
A few participants mentioned that they learned from community preceptors how to maintain good relationships with patients. One participant said she learned how to show empathy for patients through the words and actions of the community preceptors (eg, listening to patient complaints quietly, acknowledging and praising patient progress and giving patients their personal recommendations if they faced challenges). The participants were surprised that the patients in the community had such high trust in the community preceptors and were willing to share their private information with them.
They know a lot about their patients, even their family members and family relationships. They understand whether the patient would follow their advice … The performance of the preceptors, like ways of speaking and eye contact, is easier for patients to accept. That’s what we’re eager to learn. (Participant 20, male, PGY-3)
Training preferences
Some participants reported a preference for encountering patients with common chronic diseases who had developed new or atypical disorders. They believed that these cases would provide greater opportunities to improve their clinical skills and knowledge, thereby enhancing their overall competency at clinicians. This preference for complex cases may also be attributed to the residents’ desire to learn and apply novel diagnostic and treatment strategies. However, the participants acknowledged that managing complex cases could pose greater challenges in terms of decision-making, communication, and collaboration with other healthcare providers.
If we encountered diabetic patients with complaints of dizziness or abdominal pain, these types of cases are excellent for improving our clinical abilities. These types of cases can challenge our diagnostic skills and allow us to practice effective communication and physical examination techniques with patients … We can learn how to provide comprehensive care and manage a variety of health concerns that we may encounter in our future practice. (Participant 10, male, PGY-3)
Most participants recommended that having two to three residents in each half-day outpatient training session was appropriate. They perceived this as beneficial because it allowed them to observe and learn from their peers’ performances. The participants also noted that having multiple residents facilitated discussions during the feedback sessions, allowing for a broader range of perspectives and insights that were considered conducive to creating a supportive learning atmosphere.
While one resident is seeing the patient, the others can observe and take notes. After the consultation, we can sit together and discuss our experiences and learning points. This not only provides an opportunity for us to compare our performances, but also allows us to learn from each other’s strengths and weaknesses. (Participant 8, female, PGY-3)
Several participants expressed a preference for indirect supervision, whereby community preceptors observed the interactions between residents and patients from another room through video. While some participants felt a sense of security with preceptors in the clinic, others believed that indirect supervision could foster greater independence and promote greater autonomy in decision-making. They believed that this mode of supervision was more effective for developing clinical competencies.
I do prefer that preceptors not be physically present in the room but instead monitor our performance through video. This approach helps me feel more independent in my decision-making process, but at the same time, it provides a sense of security knowing that the preceptors are still observing and providing feedback. (Participant 4, female, PGY-3)
Recommendations for training improvement
GP residents commonly regard patient selection as an important issue requiring greater attention. While some participants voiced concerns that patients with complex illnesses may be better served by specialists as well as be relatively rare in primary care settings, others argued that patients with relatively simple conditions may not present sufficient opportunities for residents to acquire new knowledge and skills.
I personally think that diabetes and hypertension are common … While they are important and relevant, there may not be much room for further exploration or discussion, as patients with these conditions are usually diagnosed and treated with established plans. I think it would be more beneficial to encounter cases that are challenging and have the potential to expand my knowledge and skills. (Participant 2, male, PGY-3)
Many participants indicated the importance of expanding patient recruitment methods to increase the diversity of patients during outpatient training sessions. Suggestions for achieving this goal include establishing a shared patient database accessible to all community preceptors and organising public awareness campaigns to promote training programmes. Additionally, a few participants recommended ensuring patient satisfaction, as they may act as positive promoters and attract more patients to participate.
It’s crucial to provide high-quality patient care in our training sessions … The community healthcare centers could organize some publicity activities highlighting the advantages of our program. And of course, it’s important to ensure that the patients are satisfied with the service provided. If they have a good experience and feel like their problems were addressed, they are likely to spread the words to their friends and family. (Participant 18, male, PGY-3)
Several participants raised concerns about the practicality of the skills they had learned during the outpatient training. They noted that GP residents typically spend over 20 min with each patient, whereas in primary care settings in China, GPs usually spend only approximately 5 min per patient. They suggested that learning how to improve the efficiency of patient consultations should be prioritised. Although some preceptors suggested that residents should focus on key points and control the pace of the process, many participants felt that specific guidance on how to achieve this was lacking.
Well, I understand the importance of taking time with patients, but in reality, community healthcare centers are often crowded, and it may not be feasible to spend half an hour on each patient. I suppose that we need to be trained in how to see and communicate with patients quickly and efficiently. (Participant 3, female, PGY-3)
Several participants proposed video-recording their training sessions to assess and improve their performance. They believed that such recordings would provide an overview of their interactions with patients, highlight their strengths and weaknesses, and facilitate a better understanding of the feedback provided by community preceptors. One participant suggested that these recordings could serve as valuable resources for studying the outpatient training programmes.
There were times when I felt a little lost when the preceptor gave me feedback. I was so anxious that I couldn’t recall what I did during the patient consultation. That’s why I think it would be great to collect data, like audio and video recordings. By analyzing these materials later, we could identify areas that need improvement. (Participant 13, female, PGY-2)
Discussion
To our knowledge, this is the first qualitative study exploring GP residents’ experiences and perceptions of outpatient training in primary care settings in China. Through in-depth interviews with 20 GP residents, our study focused on the training process, the perceived benefits and challenges of the training, and recommendations for improvements.
Our study highlights the effectiveness of outpatient training in primary care settings in enhancing the clinical competencies of GP residents. The findings suggest that the opportunity to apply learned knowledge and skills to real patients in a supportive and constructive environment increases residents’ confidence. The findings are consistent with previous studies that have shown the benefits of practical training in primary care settings.16 23 Although previous studies have used standardised patients (SPs) to simulate specific diseases and enhance residents’ clinical skills,24–26 our study suggests that real patients can provide unique training opportunities to improve patient-centred care in real-world healthcare environments. Future studies should explore the long-term impact of outpatient training using SPs versus real patients on GP residents’ professional competencies and patient satisfaction outcomes in order to determine the most effective training methods for GP residents.
Our findings suggest that encounters with patients with atypical or new disorders were preferred by GP residents, as these cases facilitated the application of novel diagnostic and treatment strategies. However, the challenges posed by complex cases and medication use should not be underestimated. Residents need to develop decision-making, communication and collaborative skills to effectively handle such cases. In addition, the preference for having multiple residents in each patient session suggests the benefits of peer learning, which allows residents to observe and learn from each other’s performance. Learning from peers has been shown to be an effective way to acquire new knowledge and skills, promote critical thinking and foster a supportive learning environment. Peer observation and feedback in clinical settings have also been shown to be effective in improving clinical skills and performance.27 28
Our findings suggest that community preceptors play a significant role in observing residents’ performance and providing constructive and encouraging feedback. Feedback provided by the preceptors following patient consultations is important for improving residents’ clinical knowledge, skills and ability to provide patient-centred care. This aligns with previous research emphasising the positive impact of feedback on medical education and training.29 However, feedback from the preceptors must be specific, focused and individualised to be effective. Training sessions should focus on improving the feedback process to make it more specific and personalised for each resident. Moreover, we found that community preceptors emphasise family support and emotional status in patients, which highlights the need for GP residents to consider social determinants of health in their practice. This practice is in line with a review by Rosland et al that suggested the importance of family support in promoting successful outcomes in patients with chronic conditions.30 Overall, community preceptors are key stakeholders in the success of outpatient training in primary care settings, and it is necessary to explore best practices for preceptor training and feedback to optimise the training process.
In our study, the use of indirect supervision through video observation was preferred by several participants as it fostered greater independence and autonomy in decision-making. Indirect supervision through video observation has been recognised as a viable method of healthcare education because it facilitates self-reflection, self-directed learning, and increased independence and autonomy in decision-making.31 Studies have shown that video observation can be used to assess and enhance clinical competencies in healthcare professionals, including medical residents.32 33 Our study contributes to the literature by highlighting GP residents’ preference for indirect supervision through video observation. The effect of this method on the development of clinical competencies among GP residents also needs to be examined in future studies. Such research could establish best practices for using video observations to improve the effectiveness of outpatient training in primary care settings.
The concerns raised by GP residents regarding the practicality of the skills they learned during the outpatient training reflect the challenges that GPs face in primary care settings. Several studies have highlighted the time constraints of GPs in many countries, including China, which affect the quality of primary care.34–36 One possible approach to address this issue is to use technology, such as electronic health records and telemedicine, to streamline the consultation process. This has been shown to improve patient outcomes and increase efficiency.37 38 Moreover, participants in this study expressed concerns about barriers to patient recruitment. Research has reported that a patient-centred approach can improve patient satisfaction and lead to better health outcomes.39 40 Therefore, efforts should be made to ensure patient satisfaction by instituting training programmes to promote positive outcomes and attract more patients.
This study has several important implications for research and practice. First, GP residents perceived the distinct benefits and challenges of outpatient training in primary care settings; therefore, in the future, quantitative methodologies (eg, clinical skill examinations or scales) should be used to measure the effectiveness of training sessions across various dimensions of clinical performance and to identify areas that need improvement. Second, the teaching abilities of community preceptors are essential in outpatient training because their feedback constitutes the principal source of knowledge acquisition for GP residents. However, the number of qualified community preceptors remains small, and many are less professional and have inadequate training in guiding GP residents. Therefore, it is vital for the community healthcare training base and the standardised GP training base in China to explore approaches to improve the competencies of community preceptors, as well as increase the total number of qualified community preceptors. Finally, the recommendations proposed by the participants indicate that there is room for improvement in the outpatient training process. Future research is needed to explore the implementation of novel training practices, such as indirect supervision through video observation, as this could help improve the effectiveness of outpatient training in primary care settings.
Limitations
Our study has several limitations that should be considered when interpreting the findings. First, the study participants were recruited from a single teaching hospital in China, and the results may not reflect the wider population. However, to increase the sample diversity, we used maximum variation sampling to recruit participants from 16 medical institutions across two provinces, ensuring some diversity in the data. Second, participants’ recall bias might have affected their responses if they had different experiences with outpatient training at different times. To mitigate this bias, we included participants who had attended outpatient training sessions multiple times and excluded those who had not attended them for more than 6 months. Third, one of the interviewers had prior experience as a trainer in the teaching hospital and worked with a few participants, which might have influenced the results. However, the familiarity between the interviewer and participants allowed for a more open and candid communication, potentially enabling a deeper exploration of the participants’ perspectives. Besides, we took measures to minimise potential bias by ensuring that the study was conducted in a transparent and rigorous manner, and data analysis was performed independently using established qualitative research methods.
Conclusion
The outpatient training in primary care settings is essential for GP residents in China to improve their professional competencies, as it provides opportunities for residents to use their learned knowledge and clinical skills to deal with real patients in a constructive environment. Although the GP residents reported that their current training and the abilities of community preceptors largely satisfy their needs, they face several challenges in outpatient training in primary care settings. Future research should focus on evaluating the effectiveness of such training programmes and explore approaches to address the potential barriers.
Data availability statement
Data are available upon reasonable request. The transcripts used during the current study are available from the corresponding author upon reasonable request (zhijiexu@zju.edu.cn).
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Second Affiliated Hospital of Zhejiang University School of Medicine Ethics Committee (ID: (2022)伦理研第(0294)号) and the research was conducted in accordance with the principles outlined in the Declaration of Helsinki. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank Editage (www.editage.cn) for English language editing.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors were involved in the study concept and design. LW and ZX conducted the interviews, and LW and YT transcribed the interview recordings. LW and YT initially analysed the data and discussed the results with ZX, YY and XY. YZ and MX contributed to the conception and design of the study. The first draft was written by LW. YG, ZS and ZX drafted the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript. ZX is the guarantor and accepts full responsibility for the work, had access to the data, and controlled the decision to publish.
Funding This work was supported by the Medical Science and Technology Project of Zhejiang Province (grant no. 2023KY762, 2022KY815, 2021KY707, 2021KY711) and Scientific Research Fund of Zhejiang Provincial Education Department (grant no. Y202148336).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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