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Education in general practice

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Education in general practice encompasses education as it applies to all general practitioners (GPs) in a variety of contexts. Opportunities for teaching, learning, supervising, mentoring, or role modelling occur within the practice or outside it, and educational skills may be used by GPs in their interactions with other health professionals, peers, students, individual patients, or community groups.

Teaching is an integral part of good medical practice.1 While adages such as ‘see one, do one, teach one’ reflect the long history of intertwined clinical and educational practice, modern medical education no longer views a skilled clinician as automatically a skilled educator.2 Gaining the skills of an educator is an endeavour in its own right.3

Within general practice training, there have been calls to improve vertical integration of teaching and learning.4 While GPs in training cannot take final responsibility for care of patients seen by medical students,5 they can play an important role in medical student education.6-8 GPs may also be called upon to educate peers,9 support interdisciplinary learning, or provide education for local community groups. Some GPs may be interested in acquiring extended skills to become a GP supervisor or medical educator.9

Teaching occurs in many circumstances: planned and unplanned, with or without a patient present, and with single or multiple learners. There are a range of theories on adult learning,10 and the use of these theories is important for education in general practice. Learners are not empty containers into which knowledge is poured by the teacher. General practice education is experiential and is context and learner dependent. Therefore, educational approaches need to be adapted to the circumstance.

Adult learning theories suggest that adults plan, manage and assess their own learning to accomplish self-motivation and independence in their learning.11 Learners are internally motivated to learn if they understand why something is important, or how knowledge and skills can be applied practically. Consequently, active learning methods are most effective using strategies such as case-based learning.11,12

Coaching is an essential technique. Coaching differs from mentoring in that it does not focus just on advice and counselling but rather requires the provision of feedback and a combination of questioning, challenging, and encouragement to help the coached person achieve their full potential.12 There is no one right way to coach a learner, the most appropriate approach will depend on the individual coaches and learners involved.13

Feedback is an essential tool of coaches and an indispensable element of effective clinical learning.14 Feedback should be dialogic, specific, in real time, and learner-focused to help them achieve their goals.12 There is no one-size-fits all approach to feedback. When, how, and by whom feedback is delivered matters.15

Feedback also does not occur in a vacuum; learning cultures facilitate and constrain the exchange of good feedback. The ‘learning environment’, which includes the psychological states and relationships between participants,16 significantly impacts how feedback occurs.17,18 While transformative learning can eventuate from disorientating discomfort,19 unsafe experiences can be damaging.20 It is important that learning environments are free from bullying and harassment, are inclusive and culturally safe and allow educational discourse to occur with a focus on improvement.1,21,22

Learning also occurs through observing and imitating others.23 Medical students view GP trainees, as well as supervisors, as role models and identify this as one of the most important ways they learn.24 Role-modelling of both positive and negative behaviours can influence the formation of a learner’s professional identity,24 and it is therefore an important role for all GPs to facilitate learning for peers and those less experienced than themselves.

References
  1. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Melbourne: Ahpra, 2020 [Accessed 13 February 2021].
  2. Reedy G, Jones A. Faculty development. Becoming a 'clinician as educator'. In: Delany C, Molloy E, editors. Learning and teaching in clinical contexts: A practical guide. Philadelphia: Elsevier, 2018; p. 323–33.
  3. Stoddard H, Brownfield ED. Clinical-Educators as dual professionals: A contemporary reappraisal. Acad Med 2016;91(7):921–24.
  4. Dick MLB, King DB, Mitchell GK, Kelly GD, Buckley JF, Garside SJ. Vertical Integration in Teaching And Learning (VITAL): An approach to medical education in general practice. Med J Aust 2007;187(2):133–35.
  5. Wearne S, Butler L, Jones J. Educating registrars in your practice. Aust Fam Physician 2016;5/01;45:274–77.
  6. Jones M, Kirtchuk L, Rosenthal J. GP registrars teaching medical students - an untapped resource? Educ Prim Care 2020;31(4):224–30.
  7. Dodd J, Vickery A, van Osch H, Emery J. General practice registrar teaching roles: Is there a need for shared understanding? Aust Fam Physician 2009;38(1/2):77.
  8. van de Mortel TF, Silberberg PL, Ahern CM, Pit SW. Supporting near-peer teaching in general practice: A national survey. BMC Med Educ 2016;16:143.
  9. Cooke G, Farrell E. Registrar medical educators--experiences in the Australian General Practice Training Program 2005-11. Aust Fam Physician 2012;41(6):430–32.
  10. Mukhalalati BA, Taylor A. Adult learning theories in context: a quick guide for healthcare professional educators. J Med Educ Curric Dev 2019; 6:2382120519840332.
  11. Taylor DCM, Hamdy H. Adult learning theories: Implications for learning and teaching in medical education: AMEE Guide No. 83. Med Teach 2013;35(11):e1561-e1572.
  12. Lovell B. What do we know about coaching in medical education? A literature review. Med Educ 2018;52:376–90.
  13. Stoddard HA, Borges NJ. A typology of teaching roles and relationships for medical education. Med Teach 2016;38(3):280–85.
  14. Watling CJ. Unfulfilled promise, untapped potential: Feedback at the crossroads. Med Teach 2014;36:692–97.
  15. Kluger AN, van Dijk D. Feedback, the various tasks of the physician, and the feed forward alternative. Med Educ 2010;4:1166–74.
  16. Shochet RB, Colbert-Getz JM, Levine RB, Wright SM. Gauging events that influence students’ perceptions of the medical school learning environment: Findings from one institution. Acad Med 2013;88(2):246–52.
  17. Hutchinson L. Educational environment. BMJ (Clinical research ed) 2003;326(7393):810–12.
  18. Molloy E, Bearman M. Embracing the tension between vulnerability and credibility: 'Intellectual candour' in health professions education. Med Educ 2019;53(1):32–41.
  19. Greenhill J, Richards JN, Mahoney S, Campbell N, Walters L. Transformative learning in medical education: Context matters, a South Australian longitudinal study. J Transform Educ 2018;16(1):58–75.
  20. Wilkinson TJ, Gill DJ, Fitzjohn J, Palmer CL, Mulder RT. The impact on students of adverse experiences during medical school. Med Teach 2006;28(2):129–35.
  21. Department of Health. Aboriginal and Torres Strait Islander Health Curriculum Framework. Canberra, ACT: Department of Health, Commonwealth of Australia, 2014.
  22. Molloy E, Ajjawi R, Bearman M, Noble C, Rudland J, Ryan A. Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task. Med Educ 2020;54(1):33–9.
  23. Bandura A, Walters RH. Social learning theory. Prentice-hall Englewood Cliffs, NJ, 1977.
  24. Sternszus R, Macdonald ME, Steinert Y. Resident role modeling: “It just happens”. Acad Med 2016;91(3):427–32.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • adjust communication to the context, such as small group or individual teaching
 1.1.5, 1.1.6, RH1.1.1, 1.3.2
  • articulate thought processes and clinical reasoning when presenting information to others
 1.1.3, 1.1.4, 1.1.6, RH1.1.1, 1.2.1
  • explain and demonstrate techniques and strategies for effective communication in challenging situations
 1.1.2, 1.1.4, 1.3.2
  • use communication skills in challenging teaching situations such as disruptive participants in groups or giving feedback about poor performance
 1.1.2, 1.1.4, 1.1.6
  • deliver effective written feedback in the context of reports for learners about written or observed tasks
 1.1.2, 1.1.5, RH1.1.1
  • demonstrate the ability to evaluate individual learners’ needs and adapt the educating style to suit
 1.4.1, 1.4.3
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • deliver education that is based on up-to-date evidence
 2.2.1, 2.2.2
  • plan and deliver a structured education session that includes writing effective learning outcomes and utilises adult learning principles
 2.3.1
  • use a variety of education strategies in formal and informal settings
 2.1.8, 2.1.10
  • seek and provide feedback that is balanced, learner-centred, specific, and has a positive impact on learning
 2.3.4, 2.1.10
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • teach health promotion skills and strategies including having difficult preventive health conversations
 2.2.1, 2.2.2
  • identify and address the social, environmental and cultural barriers to education in the local environment
 2.3.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • manage professional boundaries when working with others in a teaching, mentoring or coaching role
 4.1.1, 4.1.4, 4.1.5, 4.3.3
  • recognise and acknowledge the imbalance of power in the learner–teacher relationship
 4.2.4, AH4.2.1
  • reflect on the effectiveness of their teaching approach and evaluate own performance 
 4.2.1, 4.2.2
  • demonstrate a safe and respectful approach during in-practice or workplace training
 4.1.4, 4.3.3, AH4.2.2
  • manage personal barriers and expectations to education
 4.2.2, 4.2.5, AH4.3.1, RH4.2.1, AH4.2.1, RH4.2.2, AH4.2.2
  • identify and support learners in difficulty
 4.3.3
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • manage time effectively when supervising learners in practice
 5.1.3
  • create a teaching environment in the workplace that is culturally safe, respectful and conducive to learning
 5.2.5, 5.2.6, AH5.2.1
  • write effective and defensible reports based on evidence about learners especially in the context of assessments
 5.2.1, 5.2.3, 5.2.4, 5.2.6

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Ask questions before giving answers – you will encourage better learning using this approach. It can also give you information about what the learner already knows and what help they want. Expect and encourage learners to question all the answers.
  2. Keep the goal in mind. What are the learning outcomes you hope to achieve? For example, do you want the learner to gain knowledge of the pharmacological therapies for diabetes, or be able to identify splenomegaly, or have a structured approach to abdominal pain, or understand the different ways to break bad news and be able to apply them appropriately? Knowing the end outcomes will help you tailor your approach.  
  3. Don’t try to teach too much in one go. One or two things learnt well is a reasonable outcome.
  4. Teaching opportunities can arise in many situations. Not all teaching occurs in formal sessions. An informal discussion about a problem or answering a question can be a very effective teaching opportunity because it occurs in the clinical context. Explore strategies for effective educating in different situations; for example, the one-minute preceptor.
  5. Don’t underestimate your impact as a role model for other learners, including students. Research has consistently demonstrated that learners gain an understanding of the values and ideology of the profession by observing the behaviour of those they aspire to be like. That might be you! Even if you are not aware that you are teaching, learners are learning – from you, your reflective practices, your thinking, your interactions with staff and patients, how you write notes, and so on.
  6. Sharing your own uncertainties can be valuable teaching. Teachers don’t need to have all the answers. Admitting when you don’t know and showing how you manage this uncertainty is a powerful demonstration of how you manage the uncertainty of general practice. Your learner will be more inclined to share their uncertainties, and it becomes an opportunity for you both to explore how to find answers to questions and learn together! 

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Education in general practice

You are a GP in training, working in a regional group general practice. You have been asked by the GP supervisor to run a teaching session for the final year medical student on lower back pain. The one-hour session is scheduled in the following week.

Questions for you to consider Clinical exam assessment area Domains

How would you decide what to include in this session?

How would you ensure cultural safety for your learner in your teaching session? What if the student identified as Aboriginal or Torres Strait Islander?

How might role play be used as a learning activity for the student in this session?

What techniques would you use to ensure the session is interactive?
  1. Communication and consultation skills
 1,2,5

What would you like to know about the student that would help you plan the session?

On reflecting on your own clinical practice in assessing and managing back pain, what important lessons could you share?

Does your supervisor have any areas they would like you to include in the session?  
  1. Clinical information gathering and interpretation
 2   

If the student wants to use this session to discuss a case, how could you use this to maximise their learning?  

What are the main learning outcomes you think are important for this session?

How would you approach this if these outcomes don’t align with the student’s outcomes?
  1. Making a diagnosis, decision making and reasoning
 2   

What resources might you use to enhance the student’s understanding of clinical reasoning?

What specific teaching activities could you use to achieve optimum learning?
  1. Clinical management and therapeutic reasoning
 2   

In setting up the session, what would you do to create an environment conducive to teaching and learning?

How would you approach this task differently if you were asked to run an education session for the other doctors in the practice? Or for a community group?

Are there other health professionals in the community that you could suggest the student spend time with to further their knowledge of back pain management?
  1. Preventive and population health     
 1,2,3

How will you know that your teaching session has been effective?

How will you ask for and receive feedback about your teaching? How could you incorporate this into your own learning plan for education?

If the student became distressed during a case discussion, how would you manage this?

What information would you share with the medical student’s supervisor about the student’s participation in the session?
  1. Professionalism
 4   

How could you ensure your teaching session covered all the domains of general practice?

What organisational legal dimensions should be mentioned?

If you or the student wished to discuss a patient, how would you ensure confidentiality?

How would you explain to a patient and get their consent if this was a teaching session with the patient present? 
  1. General practice systems and regulatory requirement
 5   

If the student wanted you to teach them how to instruct a patient to do back exercises, what steps would you plan for in your session? What techniques are required to ‘teach a skill’?

If you decide to include examination of the back, how will you go about instructing this?
  1. Procedural skills
 2   

In general practice, there is often uncertainty. How could you work through this in the case of lower back pain? How could you help guide the medical student on managing uncertainty in low back pain?
  1. Managing uncertainty
 2   

How could you support the medical student to understand how to safety-net? Did you consider this part of your presentation?

Did you include red flags in your presentation?
  1. Identifying and managing the significantly ill patient
 2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Consider the role of a GP role model.

  • Do you consider yourself a role model? Who are you a role model for? What behaviours do you feel you role-model well? Which ones do you need to work on? Does reflecting on your role as a role model change your practice at all?
  • Does your role-modelling align with good medical practice?

The good teacher is more than a lecturer: the twelve roles of the teacher which described the 12 roles of the medical teacher. 

  • Do you agree with these? What do you think of these roles? What roles do you find easy to do, which ones are harder?

Read Random case analysis A new framework for Australian general practice training analysis and identify the rationale for this approach. 

  • How did you go? What elements did you identify? Could you do this with a learner? Was it a helpful education method?
With a supervisor

Ask your supervisor about a recent challenging case of theirs and reflect on their diagnostic and management reasoning. You could also watch your supervisor undertake a consultation and ask them to reflect on this case.

  • How did the supervisor’s reflections help you to a deeper understanding of being a GP?
  • Think about how your own reflections of your experience might be useful in teaching someone else.

Discuss with your supervisor how they go about giving negative feedback and acting on negative feedback that they receive.

  • Reflect on how well their description is balanced, learner-centred, and specific.
  • What has worked for them before? What hasn’t worked? Do they use the same feedback style every time? What do they find most challenging and how do they manage that? How do they process negative feedback? What strategies do they use to help action this feedback?
In a small group

Plan a topic to present to a small group, such as the other doctors in your practice. Alternatively, deliver an education session to your peers.

  • Discuss the plan as a group.
  • If you delivered a teaching session, ask for feedback on your teaching style and how well you managed the group.
  • Reflect on how well the group engaged with your teaching.

Discuss with your group how cultural background needs to be considered when teaching.

With a friend or family member

Ask a (non-medical) friend or family member to nominate a topic for you to teach them. Make a plan for your teaching.

  • Ask your friend how well they understood your teaching. Ask them to summarise what they learnt.
Teach your friend a non-medical skill
  • Evaluate how well they learnt the skill.

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand adult learning theories, and how these apply to learning in general practice.
  • Understand the importance of a curriculum and syllabus, including the role of the hidden curriculum (the unofficial, unintended lessons, values and perspectives that learners/patients learn).
  • Take part in and lead case-based learning through:
    • opportunistic response to questions
    • random case analysis
    • formal case-based discussion.
  • Be able to provide planned teaching in group and individual situations in online, remote, and face-to-face settings and by using a variety of teaching strategies and planned activities; for example, use of questions, role play and simulation.
  • Be able to teach a procedure through role-modelling and providing specific instruction and coaching.
  • Effectively give and receive specific, learner-centred feedback, both oral and written, that is tailored to the learner and the individual situation.
  • Demonstrate coaching skills, including questioning, supporting and guiding learners to learn a new skill or behaviour, in both formal and informal situations.
  • Appreciate what makes a positive learning environment and understand the impact this has on learning.
  • Be able to identify, assess and apply the evidence used in medical education.
  • Understand how to evaluate the effectiveness of teaching.
  • Ensure teaching that involves patients directly or indirectly; for example, through case discussion; consider confidentiality and consent.
  • Be able to provide education to patients and their caregivers that is tailored to their needs and level of health literacy.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
An overview of coaching a learner in medical education. An approach to case-based discussion that can be used in general practice. Using random case analysis for performance review in team meetings. This article highlights 12 different roles involved in being a teacher. Practical tips and strategies for clinical teaching.
Textbooks
A comprehensive text on teaching communication and consultation skills to students and doctors.
  • Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. 2nd edn. Abingdon, UK: Radcliffe Medical, 2005. (Available from the RACGP library.) 
A comprehensive text covering many areas of medical education set out in easy-to-read chapters.
Online resources
A range of educational resources, including practice guides, flash cards and teaching plans. Tips written for teachers on the front line covering a wide range of clinical teaching topics.
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
    • Teaching and learning
    • Feedback
    • Assessment and evaluation
    • Dealing with difficulties
The content of this unit can be applied to all aspects of general practice, so is relevant to all other units.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/education-in-general-practice 12/09/2024