Introduction
A significant proportion of the complaints encountered in general practice are ENT-related. Within primary care, between 15 and 20 per cent of adult presentations, and up to 50 per cent of paediatric presentations, are ENT-related.Reference Griffiths 1 , 2 Furthermore, ENT problems are highly prevalent in the general population, with up to 20 per cent complaining of ear symptoms including tinnitus and vertigo, and 30 per cent complaining of recurrent sore throat.Reference Hannaford, Simpson, Bisset, McKarrow and Mills 3 Consequently, it is important that secondary care providers are confident in their knowledge base and experience within the field of ENT. This enables correct diagnosis and management, and appropriate referrals for specialist opinion.
Within medical education, there are three distinct settings in which training can occur: as part of undergraduate or post-graduate qualifications, and in practice through continuing medical education by way of courses and e-learning.Reference Hu, Sardesai and Meyer 4
Previous studies have identified a large variation in ENT exposure at the undergraduate level, with six UK medical schools not having any compulsory ENT attachments and 42 per cent of students not having any formal assessment in the area.Reference Mace and Narula 5 Furthermore, studies investigating the ENT experience of current general practitioners, both within the UK and internationally, have identified a large gap in the training system. A UK survey of 500 general practitioners found that nearly half felt that their previous ENT experience (both undergraduate and post-graduate) was inadequate, with up to 75 per cent reporting that they would like further ENT training.Reference Clamp, Gunasekaran, Pothier and Saunders 6 The current UK system for general practitioner training involves 18 months of placements in general practice, and 18 months rotating through a variety of specialties including acute medicine, paediatrics, psychiatry and ENT. None of these specialties are compulsory, leaving many trainees with a subjective lack of experience in areas including ENT. 2
As specialists in the area of ENT and medical educationists, we can contribute to addressing this unmet training need through running and delivering courses and tutorials. Courses for non-specialists, such as the Royal College of Surgeons’ ‘Otolaryngology (ENT) for General Practitioners’ practical skills training course, are available but are infrequent, and delegates may need to travel significant distances to attend.
This study aimed to identify the current ENT experience (both in undergraduate and post-graduate training) of general practitioner trainees within the South West Peninsula area (Devon and Cornwall). A secondary aim was to assess how confident trainees were in managing ENT complaints, and whether they felt further training by way of ENT rotations and courses was needed.
Materials and methods
Ethical considerations
There were no ethical issues raised within this study. The survey was completely anonymous and no personal data were requested other than gender.
Study design
A short, anonymous, web-based survey was created using the SurveyMonkey online resource (SurveyMonkey, Palo Alto, California, USA). This consisted of 12 questions capturing basic demographics and exploring perceptions of ENT experience and training using multiple choice questions and free text options (Appendix I).
The survey was disseminated via e-mail and limited to one submission for each participant. The survey was open for 12 months from January 2015, with multiple e-mail reminders sent during that time.
Data were collated on a Microsoft Excel spreadsheet (Microsoft, Redmond, Washington, USA), and analysed using descriptive statistics.
Setting
The survey was developed by an ENT department within a district general hospital, and was distributed to trainees in general practice through the regional post-graduate school of primary care.
Participants
The survey was emailed out to all 200 individuals on the general practitioner training scheme as at January 2015. There were no exceptions or exclusion criteria. Respondents received no remuneration for completing the survey.
Results
Demographics
The survey response rate was 60.5 per cent (121 respondents from 200 invitees). The respondents consisted of 85 females (70.2 per cent) and 35 males (28.9 per cent). The distribution of specialty trainees in years 1, 2 and 3 of training was 21 (17.4 per cent), 44 (36.4 per cent) and 55 (46.3 per cent), respectively.
ENT experience
With regard to undergraduate training in ENT, the most common amount of time spent in ENT was one week or less (43 per cent, n = 52). A total of 17 trainees (14 per cent) had no undergraduate placements in ENT, and only 10.7 per cent (14 trainees) had more than 4 weeks attached to an ENT department. During post-graduate training, the majority of respondents (59.5 per cent, n = 72) had no rotation within an ENT department. Of the remaining 49 trainees with experience in an ENT post, 4 had completed more than 1 year, 21 had completed between 4 months and 1 year, 18 had completed less than 4 months and 6 had completed less than 1 month (Figure 1).
Time spent by general practitioner trainees in ENT posts during post-graduate training.
Sixty-five per cent of respondents (n = 78) had not received any formal ENT teaching or attended courses since graduating. Of the 43 trainees who have attended a course or training session, the average duration was 1 day (n = 28, 66.7 per cent). Only two trainees (4.8 per cent) had more than 1 day of training, and the remaining eight trainees attended half a day of ENT teaching.
ENT knowledge
With regard to self-ratings of confidence in their knowledge of ENT presentations in primary care, 2.5 per cent of respondents (n = 3) felt very confident, 40.8 per cent (n = 49) felt confident, 30 per cent (n = 36) were unsure, 24.2 per cent (n = 29) felt unconfident and 2.5 per cent (n = 3) felt very unconfident (Figure 2). Two participants (1.7 per cent) did not answer the question.
Summary of responses regarding general practitioner trainees' confidence in their knowledge of common ENT problems.
Further experience
Ninety-one trainees (75.8 per cent) would have liked an ENT post during their post-graduate training, with 19 respondents (15.8 per cent) being unsure and only 10 (8.3 per cent) answering ‘no’ to this question. Of the trainees, 93.4 per cent (n = 113) reported that they would attend a 1-day course on ENT if provided locally, with only 5 per cent (n = 6) saying they would not attend such a course and 1.7 per cent (n = 2) being unsure.
Discussion
This survey highlights issues raised previously regarding limited exposure to ENT during general practitioner training, which leaves trainees lacking confidence in their ENT knowledge base. It demonstrates the need and desire of current general practitioner trainees for further ENT exposure and training, both by way of placements and relevant courses.
Comparison with previous studies
Previous studies demonstrated that the average time spent in an ENT placement was one week or less (41.6 per cent), with 15.7 per cent of trainees having no ENT placements in undergraduate training. The current amount of undergraduate ENT exposure has been deemed inadequate by current consultant otolaryngologists and general practitioners. Both groups suggest that an increase in the amount of ENT exposure offered is required to equip junior doctors with the relevant skills and knowledge needed to manage basic ENT complaints.Reference Clamp, Gunasekaran, Pothier and Saunders 6 , Reference Khan and Saeed 7 Despite several papers highlighting the issue, there remains no change or improvement to the undergraduate ENT curriculum.Reference Khan and Saeed 7
ENT training and exposure does not improve throughout the career of general practitioner trainees. Only 40.5 per cent of the trainees surveyed had any post-graduate ENT experience, and a surprising 65 per cent of respondents reported that they had not received any formal ENT teaching or attended relevant courses since graduating from medical school.
Previous studies have suggested that many general practitioners lack appropriate and relevant knowledge of common ENT issues.Reference Hu, Sardesai and Meyer 4 This gap in knowledge is noted by the trainees, and demonstrated in this survey, with less than half of the respondents (43.3 per cent) reporting feeling confident in managing ENT problems and over one-quarter (26.7 per cent) feeling unconfident. This is especially prudent considering that ENT-related complaints comprise such a significant proportion of general practice. Inadequate knowledge and experience may lead to suboptimal patient care and inappropriate referrals to local otolaryngology departments. Although guidelines exist to assist general practitioners, they are often underutilised. 2 However, when asked, 62.7 per cent (n = 65) of the respondents to this survey reported that they would use such guidelines when managing ENT complaints in the community and only 0.8 per cent (n = 1) would seek specialist advice.
Effect on tertiary referrals
It is not known how much the variability in ENT exposure affects referral rates. Studies have attempted to answer this question, but results have been unreliable. A survey of 500 general practitioners in South West England identified that referral rates to secondary care for ENT issues varied from 0 to 50 per cent of those seen with ENT issues (average of 5.4 per cent).Reference Clamp, Gunasekaran, Pothier and Saunders 6 However, these results were dependent on subjective estimates made by the general practitioners themselves. Furthermore, the wide range in values made statistical analysis difficult. However, the authors did find that there was a slight increase in referral rates amongst those general practitioners who had the least ENT experience, but this difference was not significant (p = 0.079).Reference Clamp, Gunasekaran, Pothier and Saunders 6
Can ENT training be improved?
Most trainees (75.8 per cent, n = 91) would have liked an ENT post during their training; however, it is unrealistic to think that this is achievable for everyone because of limited training time and possible limitations in the availability of ENT posts. ENT departments could offer training courses to address this unmet need.
Mace and Narula,Reference Mace and Narula 5 and Clamp et al.,Reference Clamp, Gunasekaran, Pothier and Saunders 6 have called for further training. Perhaps the easiest means of addressing this is by offering more accessible ENT courses aimed at general practitioners. Regional ENT courses designed to improve knowledge and clinical skills could help general practitioner trainees feel more confident managing patients in primary care, and potentially reduce inappropriate referrals to secondary care.
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• Previous studies have demonstrated a lack of ENT training in general practitioners
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• This study highlights minimal undergraduate and post-graduate ENT training amongst general practitioner trainees in Devon and Cornwall
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• This ongoing issue could be addressed by providing local ENT courses as it is unlikely that all general practitioner trainees will rotate through ENT posts
Further research is needed to establish whether courses and online e-learning modules are adequate to address training needs in lieu of traditional experience gained through a rotation in ENT, and to determine whether experience in ENT objectively influences rates of referral to secondary care.
Conclusion
General practitioner trainees across the South West Peninsula region have had little ENT exposure and experience, both in undergraduate and post-graduate training. Previous studies have demonstrated that a lack of ENT training negatively affects general practitioners’ knowledge of how to manage ENT complaints, which may lead to inappropriate referrals to secondary care.Reference Hu, Sardesai and Meyer 4 The general practitioner trainees surveyed here have expressed a wish for further ENT training, specifically by way of relevant and easily accessible courses. Specialists in ENT have a role in facilitating the training of non-specialists by delivering local courses. Promoting existing courses and developing new, more frequent local ENT courses is recommended to improve post-graduate ENT training in general practice. The results of this survey serve as a baseline for comparison for future studies to demonstrate the impact of local training initiatives.
Acknowledgements
The author would like to thank the Peninsula Postgraduate School of Primary Care and Dr Mark Morris for help in distributing the survey, and acknowledge Mr Mamun Rashid for assisting with the development of questions for the survey.
