General practices need to consider a number of practical
issues when becoming a teaching practice.
This article describes the key aspects of patient and financial
management when trainees are present in the practice and
suggests solutions to potential issues.
Managing a practice where trainees are present adds
additional organisational workloads and responsibilities.
One aspect is the management of patients when trainees
are present. This includes ensuring patients understand the
requirements of a teaching practice and obtaining informed
consent from patients, particularly for more junior training
levels. It also requires the appropriate management of
appointments to allow for teaching and supervision and a
process for managing complaints and follow up.
Another aspect for a teaching practice is financial
management. Staff have additional roles which can impact on
their service roles and a number of factors can impact on the
income generated by a trainee.
Teaching practices need to be aware of these issues and
establish systems to enable them to manage a practice
effectively when trainees are present.
The demand for clinical placements in Australian general practice is on the rise. There are more medical students, more places available for junior doctors to undertake rotations in general practice (975 places by 2014) and more general practice registrar positions (1200 entry places by 2014).1 While this allows greater exposure of trainees to general practice and primary care, it places additional burden on teaching practices. Not only are they teaching more trainees, they are also teaching across the training continuum (Table 1). Research indicates that between 43%2 and 72%3 of supervisors in teaching practices teach more than one level of trainee.
Involvement in teaching provides a number of benefits to a practice. For supervisors these include enjoyment, adding variety to their practice, helping them learn, and exposing students to the profession.2 For practices, trainees can increase practice capacity by providing additional workforce and involvement in teaching can form part of succession planning, with registrars returning to the practice after completion of training. For patients, they appreciate longer consultations, their role in training future general practitioners and new perspectives that trainees can provide on their conditions.4 However, having trainees in the practice adds to the administrative and organisational workload and practices need to consider that the potential long term benefits outweigh the short term increase to administrative/teaching workload. This article outlines the key issues to consider in relation to patient and financial management when trainees are in a practice.
Patient management in a teaching practice
Patient participation in teaching that occurs in general practice is vital; be it for medical students, junior doctors or registrars. For this to be successful, a practice needs to consider consent, patient acceptance of trainees, staff training, time management, follow up of patient care and management of complaints. Resources that cover these topics are summarised in Table 2
Consent/patient acceptance of trainees
Table 1. Level of trainees placed in teaching practices
||Placements can occur at every year level during training. Placements can vary across medical schools ranging from less than 10 days per year to more than 20 days per year
|Junior doctor (postgraduate year PGY1–PGY3)
||Through the Prevocational General Practice Placements Program (PGPPP), junior doctors can undertake a 10–13 week placement as a PGY1 (intern) or PGY2 or PGY3 as part of their hospital training
|General practice registrar
||Registrars spend at least 18 months of their 3 or 4 years of training in teaching practices. Placements last between 6 and 12 months
An important aspect of managing a teaching practice is how patients perceive teaching. Research indicates that most patients like to be involved in teaching.5–8 However, it is important that teaching practices have clear processes regarding informing and gaining consent from patients.9–11 The information provided to patients will vary with the level of involvement of the trainee in the consultation. For medical students, patients are likely to have a dual consultation with their GP and the student. For more advanced medical students, the student may take a history with the patient without the presence of the supervisor. This means that patients need to be informed at the time of booking their appointment that a student may be present and consent to this. At attendance, the patient should be reminded of the student's presence and have the opportunity to opt out. At the registrar level, the situation is somewhat different in that they are qualified doctors and so will consult with patients without having the supervisor present. Implied consent is obtained when the patient agrees to see the registrar when booking their appointment.
Practices should also have systems in place to identify patients unsuitable for student teaching, such as patients requiring counselling, known drug seekers or patients with mental health issues as well processes for when patients opt out.
Related to consent is patient acceptance and understanding that the practice is a teaching practice. This can be done through signage or practice pamphlets. These resources should explain different training levels, qualifications of different trainees, the organisation managing their training and benefits to the patient. They can also explain how patient consent to participate will be obtained. It is important for patients to understand the qualification of each level. For example, registrars are qualified practitioners who are 'specialising in general practice'. This information can also be provided when patients are booking appointments, which also requires staff to understand the role of teaching within the practice and the different types of trainees. Once patients are aware of what is involved in a teaching practice they often view the practice more positively.
Time management and appointments
A teaching practice will manage a more complex appointment/booking system. For example, the supervisor's appointments need to allow extra time when medical students or junior doctors are present; and linking appointments with the supervisor to allow review and signing off. At the trainee level, the registrar and supervisor appointments need to allow for catch-up. Quarantined teaching time with trainees, be it tutorials, case discussions or consultation review, also need to be accommodated. At orientation, discussion should be held between the practice and the registrar about dedicated sessions where the supervisor is able to monitor the performance of the registrar (eg. sitting in on consultations).
For registrars, practices will need to provide for longer consultations at the beginning of a placement to allow them to become familiar with the practice and patients. Research undertaken in South Australia and Western Australia has estimated the time that teaching added to a GP's session across the training continuum.3,12 Teaching a general practice term GPT1 registrar added 5 hours a week, for a GPT2 it added 3 hours, while GPT3 teaching added 2 hours per week. For junior doctors it ranged from 4–6 additional hours a week and for medical students it averaged 7 hours a week.
For trainees, particularly registrars, it is also important that they see a cross-section of different clinical conditions and in some cases, limits set on particular types of appointments (eg. Pap tests with female registrars).
Managing complaints and feedback
Teaching practices also need a system to handle complaints related to the trainees. Complaints need to be fed-back to the trainee, usually by the supervisor. As with any complaints process, good documentation processes are necessary, and when trainees are involved, it is important to know who participated in the consultation.
Difficulties for the practice can also arise if a registrar does not match the 'culture' of a practice. Regional training providers (RTPs) can match registrars with a teaching practice 13 and can provide advice and feedback to practices on placements, which can help improve future placements and minimise difficulties.
Follow up of patients managed by trainees
Practices need a process for following up patients once the trainee has left the practice. This ensures continuity of care for the patient (eg. follow up of tests ordered by the trainee). Continuity of care is particularly important for obstetric patients, as registrars may only be placed with a practice for 6 months.
Financial management in a teaching practice
The decision to take on a teaching role can have a significant financial effect on a practice. Factors that impact on the practice finances include the cost associated with teaching, subsidies available, the involvement of support staff, patient base, administrative red tape and accommodation.
Cost of teaching for a practice
Two recent studies undertaken in Australia indicate that the financial costs associated with teaching, and that the subsidies provided to support this teaching, do not offset all these costs for some levels of trainers.3,12
For teaching subsidies, practices need to determine how these are distributed within the practice. Every practice will have their own way of allocating subsidies based on the individual GP's level of involvement in teaching. A practice will need a system of tracking teaching time and levels of learners, which can then be used in allocating subsidies.
The placement of a trainee within a teaching practice affects all staff within the practice. For example, trainees need to be oriented in all aspects of the practice; a task usually undertaken by the practice manager. Orientation is critical in terms of risk management. It ensures trainees are comfortable and familiar with the practice environment and can minimise disruptions in the practice. Receptionists also need to understand the booking procedures for trainees and liaise with them regarding patients and other issues, and this becomes an additional and important role for reception staff.
Other staff involved in teaching trainees include practice nurses, who may provide training in immunisation, which can then reduce their availability for other activities.
Table 2. Useful resources for teaching practices
|RACGP Standards for general practices, 4th edition
||Consent for medical students
RACGP Vocational training standards
ACRRM Standards for supervisors and teaching posts in primary rural and remote training
|Requirements for accreditation as a training practice
RACGP Guidelines for the supervision of medical students in general practice
|Guidelines for supervision of medical students in general practice
Guidelines for supervisors
Guidelines for education of medical students
Guidelines on support required
Guidelines for the practice
Guidelines on workload and monitoring/feedback
|RACGP General Practice Trainers Manual
||Guidelines for supervisors of registrars in general practice
Roles and responsibilities of trainers and practice
Practice based teaching
Teaching and learning methods
|RACGP Standards for the supervision of prevocational doctors in general practice
||Guidelines for supervision of junior doctors in general practice
Standards for the education of prevocational doctors
Standards of support required
Standards for the practice facility
Standards on workload and monitoring/feedback
|AGPT Training providing links
||Information on practices/supervisor requirements for prevocational trainees and registrars
Accreditation of teaching practices/supervisors
|GPRA National minimum terms and conditions
||National minimum terms and conditions for registrars (may vary between different providers)
Patient base for trainees
It may take time to build up a sufficient patient load to cover the trainee's base salary. Practice income can also be affected at the end of the trainee's placement when patients know the trainee is leaving and transfer to another GP.
Administrative red tape – employment contracts, insurance, provider numbers
Being a teaching practice brings added administrative tasks and if care is not taken, can have a negative financial impact. Registrars are employed under minimum terms and conditions (Table 2). They are provided with a base wage and if billings are higher, retain a percentage of these. However, if the registrar does not see sufficient patient numbers (ie. new to practice), the practice is responsible for any shortfall. For rural practices, payments to trainees is complicated by the mix of consulting room, after hours and hospital work.
It is also important for trainees to understand the Medicare Benefits Schedule and use the appropriate items for billing. If billing is done incorrectly it can reduce the income generated through rejection of claims and can also undervalue the service they provide.
The accurate completion of application forms, particularly medical provider numbers, is important and practices need to ensure that the provider number is allocated by Medicare before the commencement of the placement, as delays can be costly for the practice.
For rural teaching practices, providing accommodation for the trainee during their placement is an additional role for the practice. Practices may contribute all or a proportion of the rental cost, depending on the level of subsidies available through programs and training levels. For some locations, rents can be expensive, particularly in popular tourist regions or in mining towns. In addition to the rental cost, there is also the cost of staff time in locating appropriate accommodation or managing the accommodation.
A number of issues need to be considered when becoming a teaching practice, with patient and financial management in the forefront. We have summarised the key aspects in these two areas and, where possible, provided solutions. While this article has focused on some of the practical aspects of managing a practice where there are trainees, it should also be remembered that trainees can bring benefits to a practice. Patients like their involvement in teaching, supervisors enjoy this aspect of their work, and trainees can bring different perspectives to a practice and enhance the roles of other staff.
Conflict of interest: none declared.
- The Auditor General. General Practice Eduation and Training. Canberra: Australian National Audit Office; 2011. Report No.: Audit Report No.34 2010–11.
- Laurence C, Black L. Teaching capacity in general practice: results from a survey of practices and supervisors in South Australia. Med J Aust 2009;191:102–4.
- Laurence C, Black L. Sustainable teaching in general practice in WA Report. Perth: Western Australian General Practice Education and Training; 2010.
- Pearce R, Laurence C, Black L, Stocks N. The challenges of teaching in a general practice setting. Med J Aust 2007;187:129–32.
- Howe A, Anderson J. Involving patients in medical education. BMJ 2003;327:326–8.
- Mathers J, Parry J, Lewis S, Greenfield S. What impact will an increased number of teaching general practices have on patients, doctors and medical students? Med Educ 2004;38:1219–28.
- Sweeney K, Magin P, Pond D. Patient attitudes: training students in general practice. Aust Fam Physician 2010;39:676–82.
- Mol S, Peelen J, Kuyvenhoven M. Patients' views on student participation in general practice consultations: a comprehensive review. Med Teach 2011;33:e397-e400.
- O'Flynn N, Spencer J, Jones R. Consent and confidentiality in teaching in general practice: survey of patients' views on presence of students. BMJ 1997;315:1142.
- Williamson C, Wilkie P. Teaching medical students in general practice: respecting patients' rights. BMJ 1997;315:1108–9.
- Larsen K, Perkins D. Training doctors in general practice: a review of the literature. Aust J Rural Health 2006;14:173–7.
- Laurence C, Black L, Karnon J, Briggs N. To teach or not to teach? A cost benefit analysis of teaching in private general practice. Med J Aust 2010;193:608–13.
- Laurence C, Black L. A person-practice-program fit: evaluation of a GP training placement process. Aust Fam Physician 2007;36:666–9.