Medical students' attitudes towards increasing early clinical exposure to primary care.

Context: The sustainability of the future UK General Practice (GP) workforce is reliant on half of medical graduates choosing a career in primary care (1), but while good quality undergraduate GP placements (particularly those which are early in the curriculum and integrated into ongoing learning) have been linked to subsequent GP career choices (2), exposure has plateaued at 13% of UK undergraduate teaching time(3).Of students in UK medical schools, undergraduates at the University of Nottingham(UON) spend towards the least amount of time in primary care. 
Research questions: We set out to investigate Nottingham medical students’ attitudes towards a proposed increase in the primary care component of their “early clinical exposure” module from ten half days to fourteen full days during the first two years of the undergraduate course. We sought to assess the potential impact on perceived student learning and experience. 
Description: We recruited nine students from across the five undergraduate year groups to take part in audio-recorded semi-structured interviews which lasted 30-60 minutes. All participants provided informed consent. Having set out to include 20-30 participants in our sample, recruitment was impaired by students’ busy teaching schedules and overlapping exam seasons within the University. Interviews followed a theme guide and explored topics of exposure time, learning opportunities, and career intentions. We analysed verbatim transcripts using a constant comparative approach, assigning and grouping codes, and merging and revising categories until new data did not alter the resultant themes. We considered data to be saturated once ideas were repetitively expressed and did not prompt revision of themes. A larger sample would have strengthened confidence in our theoretical integrity. 
Outcomes: Students reported that opportunities encountered in primary care settings allowed them to contextualise their scientific learning and develop core practical and communication skills (Table 1). Their GP placements were multi-disciplinary and holistic, enabling them to build professional relationships with mentors and ultimately feel better-prepared for both their undergraduate clinical phase and future careers. Immersing students into the clinical environment at this early stage of their training provided drive and focus for their academic studies, but some students shared their awareness of a stressful GP workplace with time and administrative pressures, reflecting how this experience discouraged them from choosing GP careers. Participants unanimously supported an expansion to the timetabled early primary care clinical exposure.


Research questions
We set out to investigate Nottingham medical students' attitudes towards a proposed increase in the primary care component of their 'early clinical exposure' module from 10 half days to 14 full days during the first 2 years of the undergraduate course. We sought to assess the potential impact on perceived student learning and experience.

Description
We recruited nine students from across the five undergraduate year groups to take part in audio-recorded, semi-structured interviews which lasted 30-60 min. All participants provided informed consent. Having set out to include 20-30 participants in our sample, recruitment was impaired by students' busy teaching schedules and overlapping exam seasons within the University.
Interviews followed a 'theme guide' and explored the topics of exposure time, learning opportunities, and career intentions. We analysed verbatim transcripts using a constant comparative approach, assigning and grouping codes, and merging and revising categories until new data did not alter the resulting themes. We considered data to be saturated once ideas were repetitively expressed and did not prompt revision of themes. A larger sample would have strengthened confidence in our interpretation.

Outcomes
Students reported that opportunities encountered in primary care settings allowed them to contextualise their scientific learning and develop core practical and communication skills (Table 1). Their GP placements were multidisciplinary and holistic, enabling them to build professional relationships with mentors and ultimately feel better-prepared for both their undergraduate clinical phase and future careers. Immersing students into the clinical environment at this early stage of their training provided drive and focus for their academic studies, but some students shared their awareness of a stressful GP workplace with time and administrative pressures, reflecting how this experience discouraged them from choosing GP careers. Participants unanimously supported an expansion to the timetabled early primary care clinical exposure.
Our reflections on the study findings were that future primary care days might be enhanced by developing learning objectives to facilitate greater collaboration with the community Multidisciplinary team (MDT) and scheduling full-day placements in order to foster greater mentorship and instil professional behaviours. Furthermore, we reflected on the strengths and limitations of our qualitative methods. Further studies of a student population might be facilitated by planning evening interviews away from teaching premises, and by budgeting to incentivise recruitment. Our appointments within the institution as clinicians, educators, and researchers were known to the study participants and as such our positionality may have influenced ideas that were expressed (or not expressed). Analysis was not entirely inductive, as having declared some areas of interest prior to data collection, assimilation may have been restricted. Our experiences reiterated the need to budget sufficient time and resources for protocol and ethical planning, audio-recording equipment and transcription, and coding analysis and reflection when undertaking qualitative enquiry.

Conclusions
Our small qualitative study reiterated medical students' insight into the utility of education in the GP environment, citing opportunities to develop essential nontechnical skills and to learn holistically within a unique professional mentorship, while contextualising their scientific knowledge in real world clinical situations. Early clinical exposure in primary care reaffirmed students' motivation to train as doctors, but as educators we must be mindful that a balance must exist between offering a realistic professional experience and managing the potential deleterious impact of exposing learners to the increasing demands on GP time and administrative stressors.

Ethical approval
This was granted by the UON Research and Ethics Committee (Ref: F16012017).

Author contributions
JvO wrote the protocol, collected and analysed data and prepared the manuscript. CC analysed the data and prepared the manuscript. GS and JT wrote the protocol and manuscript. RK wrote the protocol, supervised data collection and analysis, and prepared the manuscript. Table 1. Summarystudents' opinions relating to the benefits of early clinical exposure in primary care.

Contextualised scientific learning:
-Application and integration of theory into clinical practice -Motivating students to work towards career goals Practical and communication skills: -Practical skills and clinical examination -Developing communication and consultation skills -Working independently with patients Multidisciplinary learning: -Understanding the National Health Service (NHS) -Observing and learning from other healthcare professionals Holistic learningmentor relationships, professionalism, and career planning: -Development of student/tutor relationship -Development of professionalism and situational awareness -Opportunistic learning -Career planning -Facilitating reflection