A general practice registrar thanked us for teaching her so much during her time at our practice. Her gratitude extended beyond her supervisors to the reception staff, practice nurse and manager, and other doctors who had not run formal teaching sessions. How had these other staff taught her without teaching?
Learning to be a general practitioner (GP) requires immersion in general practice. Background knowledge is essential, and practise in simulation centres can help, but an apprenticeship of learning to be a GP by being a GP is key.1 General practice supervisors and training practices affect general practice registrars’ experience of this immersion in work. This article describes how they can positively influence registrars’ learning.
What do registrars learn in practice?
Educating registrars in the practice is about passing on the art and craft of the profession (Box 1), which registrars have summarised as the difference between ‘knowing that’ and ‘knowing how’.2 Registrars have to learn the spectrum of GPs’ work in providing comprehensive primary care across people’s lifespans. They also need to develop their identities as GPs by integrating their personal values and characteristics with the norms of the profession.3 Supervisors can perceive registrars as having up-to-date knowledge, whereas registrars rapidly realise they need knowledge relevant to primary care. As a result, registrars often have to combine traditional study with in-practice experience of applying knowledge and skills in different contexts. They also need to learn how to balance patients’ needs, wishes, culture and circumstances.4
Box 1. Examples of the ‘craft’ of general practice discussed between registrars and supervisors
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Consultation management
Negotiating and prioritising with patients issues to focus on when providing ongoing, comprehensive care
Thinking logically and creatively to guide patients into addressing their problems
Closing consultations
Diagnosis
Using time as a diagnostic strategy
Rational use of investigations
Management
Navigating the health system
Saying ‘no’ to patients’ requests
Caring when cure is elusive such as complex pain syndromes
Assessing evidence and guidelines for their relevance in different contexts
Workers compensation claims
Ethical practice
Sick certification
Billing Medicare
Handling conflicts of interest and pharmaceutical promotional material
Sustainable practice
Avoiding burnout and setting boundaries
Developing resilience to keep treating ‘difficult’ patients
Learning how and when to stop seeing ‘difficult’ patients
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How do registrars learn?
The rationale for an educational alliance
General practice supervisors help registrars to navigate the messy, uncertain world of practice. They assist registrars with tasks of varying complexity, from simple process questions (eg which form to complete or which local specialist is best for which problem)5 to complex questions (eg resolving conflicting evidence or guidelines,6 or caring for people whose symptoms do not fit any particular diagnosis).7 Evidence from the Registrar Clinical Encounters in Training (ReCEnT) study showed that registrars asked their supervisors for assistance in more complex consultations.8
Applying science to individual patients with consideration of their social, psychological and cultural contexts requires empathic negotiation, which is difficult to learn from didactic instruction. Effective supervisors know their registrars holistically and openly discuss with them how their own backgrounds and assumptions transfer into their work.9 They are able to unpack the factors that affect registrars’ clinical decisions.
Communities of practice
While the supervisor–registrar alliance is foundational,10 educational research on learning at work has found the importance of a ‘community of practice’ that has expertise.11,12 A single, enthusiastic clinical supervisor is not enough. General practice registrars who learn in practices that have non-hierarchical relationships among doctors and other staff, and where knowledge and experiences are shared, are better prepared for practice.13 Everyone in a practice has expertise to share and is teaching the general practice registrar, whether consciously or not.
Role modelling and observing
Registrars learn from seeing experienced practitioners at work. This period of supervision is the last, most intensive and most appropriate place to learn the ethics and attitudes of their chosen vocation. How experienced GPs write notes, interact with staff, discuss patients and behave day to day are all educational opportunities. Even when we do not think we are teaching, registrars are learning from us, and are likely to perpetuate our behaviour through their careers.
Sitting in with GPs and other healthcare professionals to observe different consulting styles is expected in other countries14 and could be used more in Australia. In particular, international medical graduates new to Australian general practice will gain from seeing experienced GPs’ scope of practice and skills.
Coaching and reflection
Coaching is the specific process of direct instruction, such as teaching someone how to use a software program or do a procedure. Experienced GPs may need to consciously deconstruct and clearly articulate skills that have become automatic.15 Supervisors help registrars to reflect and learn16 by discussing cases in planned teaching sessions and by ad hoc teaching between or in consultations.17 Thus learning from patients is interwoven with everyday practice.18
Creating a positive learning environment
Welcoming
A thorough orientation is a good investment that initiates the educational alliance. In our experience, the extra time to ensure registrars know the computer and local referral systems, practice protocols and team members increases their confidence and productivity later on. Orientation also means getting to know registrars, and their backgrounds, experience and learning needs. This establishes a symbiotic working relationship whereby learning is tailored to registrars, who in turn contribute their skills to the practice.
Protecting registrars from the pressure of seeing too many patients is important initially. Even relatively senior registrars need time to adapt to a new practice, especially if switching from or to an Aboriginal and Torres Strait Islander health service. Later on, increasing consultation rates is valuable preparation for vocational examinations and clinical work post-qualification.
Approachable, accessible assistance
General practice registrars consistently state the importance of accessible, approachable and expert GPs as their supervisors.17,19,20 Registrars have to be confident that supervisors will welcome and respond to their questions. They can crave reassurance21 as they confront the isolation of general practice, compared with hospital practice. Registrars welcome a safe, blame-free environment.22
Patient safety
Registrars in training practices work behind closed doors and with more autonomy than during their prior experience in hospitals. Training practices oversee patient safety while registrars are learning.10,17 All practice staff have a role by observing the registrar and reporting any concerns or patient feedback. Supervisors need to supplement reactive supervision with proactive supervision by ‘looking out’ for their registrar and undertaking direct or video observation of consultations, random case analysis, or other audit activities.23
Silence is not golden for general practice supervisors. If registrars are not asking questions, it can mean that they are either aware of what they do not know but are too afraid to ask, or they do not know what they do not know. Both situations need addressing non-confrontationally.
Inclusive practices and continuity of care
Registrars need exposure to all aspects of their future work. The experience of seeing patients at home, in nursing homes or in hospitals is important. They also benefit from participating in practice meetings, and in staff and financial management.13 Continuity of care is educational as it teaches registrars the impact of their management and how problems change over time.24
Assessment and feedback
Checking the registrar’s progress is the supervisor’s responsibility, but their progress is richer for involving the whole practice. Providing feedback is essential to learning,25,26 and registrars appreciate supervisors ‘who dare to give constructive criticism’.20 We recommend making it clear at the beginning of any placement how registrars will be assessed and given feedback, when and by whom.27
Part-time supervisors
Increasing numbers of GPs are working part time, so supervision is provided by a team. One person needs to take responsibility as the main supervisor and facilitate regular communication within the supervision team. We often do this by email rather than face to face. Discussion focuses on registrars’ strengths and areas for development or extra input. Because each supervisor is seeing the registrar for less time, it can take longer to identify problems or educational issues. We leave it up to the registrar to balance the content of the weekly teaching time to prevent duplication of topics by different supervisors.
Registrars as teachers
Registrars are often the most senior learners within teaching practices. While giving registrars the chance to teach junior doctors or medical students helps their learning, it is important not to expect too much too soon. Registrars teach juniors in hospitals, but the consultant retains the clinical responsibility for patients under their care. In general practice, patients seen by registrars are rarely reviewed by supervisors, which is unusual in a training program. Registrars can teach students in tutorials or have students sitting in on consultations; however, they are not yet qualified as independent practitioners and are not capable of taking full clinical responsibility for students who see patients. Hence, supervisors need to check the notes and/or discuss each case with registrars if they are assigned students.
Rural and remote practice
General practice in rural areas usually includes on-call responsibility for emergency care and hospital work. The degree of procedural work done by general practice registrars will be determined by a hospital privileging committee. Issues of supervision can be tricky if a registrar is fully qualified in a procedural skill but needs more supervision for office-based practice. Expectations regarding supervision when registrars are on call need clarification as there is a tension between giving registrars opportunities to learn and ‘using’ them as workforce.
Registrars in remote practice face psychosocial and cultural challenges. They have to adapt to living and working in isolation, where they may not share their patients’ cultural perspectives on health and they too may lose access to healthcare. Support from cultural mentors is essential in remote Aboriginal and Torres Strait Islander communities and recommended for all registrars to promote culturally competent practice.28
Registrars on rural or remote rotations may be separated from loved ones or family, and have alternating fly-in, fly-out relationships with them and their patients. Guidelines that a GP should not see friends as patients can mean that they have either no friends or no patients.29 Registrar safety, wellbeing and navigating grey areas become central issues in supervision once registrars realise that previously taught absolutes regarding professionalism and boundaries are impractical.
Evaluation and quality control
Accreditation and educational organisations usually ask registrars for feedback to help practices improve their performance. In our practice, we supplement this with a simple internal feedback form of three questions:
- What helped you learn?
- What aspects of the practice stopped you from learning?
- What should we do differently?
Conclusion
In summary, the apprenticeship model of learning how to be a GP by working as a GP is fundamental. One supervisor needs to take overall responsibility for planning and supporting learning within the practice, and for proactive and reactive supervision. Current evidence and educational theory focuses on a teaching team and learning in a community of practice. All staff in a teaching practice can positively influence registrars towards good practice, as our own registrar acknowledged.
Authors
Susan M Wearne BM, PhD, MMedSc, FRACGP, FACRRM, DCH, DRCOG, DFFP, GCTEd, Senior Medical Adviser, Department of Health, Health Workforce Division, Canberra, ACT; Central Clinic, Alice Springs, NT; Australian National University Medical School, Academic Unit of General Practice, Canberra Hospital, Canberra, ACT. susan.m.wearne@gmail.com
Louise Butler BMedSc, MBBS (Hons), FRACGP, DRANZCOG, GradDipRuralGP, General Practitioner, General Practice Supervisor, Central Clinic, Alice Springs, NT
Jeremy A Jones BEng (Software)(Hons), BMBS, FRACGP, General Practice Registrar, Central Clinic, Alice Springs, NT
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
Acknowledgements
The authors would like to acknowledge Drs Wendy Zerk, Sue Bain and Oyekan Johnson for their input into this paper, and Drs Gerard Ingham and Bruce Willett for their constructive comments on earlier drafts.
Dr Susan Wearne asserts that this paper does not necessarily reflect the opinions of the Australian General Practice Training program or Department of Health.