A guide to managing performance concerns in general practice registrars

An assessment framework for performance concerns

Last revised: 20 Jan 2025

To effectively treat a problem, you first need to make an assessment. This is not always simple as there is often uncertainty and competing possibilities for the probable cause of the difficulty. Considering multiple causes is the way we help to manage some of this uncertainty and to ensure we are considering more broadly than the immediately obvious choices. Identifying the probable cause is necessary to develop a management plan that is going to give the greatest chance of success. Not considering a potential cause may result in missing management options that may be critical to success. Many of these causes interact. The purpose of the process is not to label an underperforming registrar; but rather to identify the behaviour/s and identify what will give the greatest point of leverage, to gain the maximum probability of success, with the least resources. There are many frameworks to assess the registrar with performance concerns. A useful one is outlined below:

A framework for assessment

  1. Pre-requisites for learning
    1. Learning difficulties
    2. Interpersonal skills
    3. Awareness of context
    4. Self-awareness
    5. Ability to learn from experience.
  2. Knowledge
  3. Skills
  4. Professionalism
    1. Roles
    2. Attitudes & motivation
  5. Systems
  6. Health of the individual & family
  7. Inherent characteristics

These are the essentials that must be present to ensure that the learner is able to learn. They include selfreflective ability, sufficient interpersonal skills to be able to interact effectively for learning, and the ability to be aware of their environment so that they may interact with it, learn from it, and translate that learning into other situations. Without these prerequisites, it is unlikely that success will be able to be gained in any other area.

a. Learning Difficulties
Unmanaged specific learning difficulties can impact on a person’s ability to learn. For example - dyslexia, difficulties with attention and other specific learning disorders (SLD) may all impact areas of learning that can set a registrar up for failure. These can be undeclared, unrecognised, and/or not managed and may become unmasked during the General Practice training program.

b. Interpersonal Skills
This relates to the broader ability to interact, communicate, and relate to others. It includes skills necessary in clinical consultations, however specific consulting skills are an additional level required for the conduct of medical consultations. For anyone to learn, they need to have the ability to effectively relate to others, not just within medicine. The ability to read emotions, respond appropriately and be articulate in speech all fall within the core components of interpersonal skills.

c. Awareness of Context
Knowledge application and behaviours are context specific. Being aware of the environment you arecurrently in enables you to store and use knowledge, skills, and behaviours relevant to that context. When someone has little awareness of their context, they do not have the ability to interpret and apply behaviours effectively for the current context and will have difficulty adapting that behaviour to different contexts. This impacts on their ability to apply knowledge and skills in an appropriate way. E.g. Sending off a tropinin
blood test on a patient is appropriate in the Emergency Department where the patient can continue to be monitored, but is not appropriate in general practice where the patient goes home and the result is not available by the end of the work day.

d. Self-awareness
Self-awareness is a foundation for self-reflection. It is critical in effective interpersonal skills. Being aware of how you present, how you interact, the impact you have on others and how you can modify this is central to learning many skills. Awareness of when you have and do not have knowledge, and awareness of your own limitations is required for active learners to seek improvement.

e. Ability to learn from experiences
This combines self-awareness and ‘awareness of context’ to progress to the next step and be able to learn from experience. The process of having an experience, evaluating it, considering other options, and developing change, forms the basis of Kolb’s (1984) cycle of learning. A registrar who lacks self-awareness and ‘awareness of context’ will be unlikely to effectively work through this cycle that is required for learning and progression. In theory, we should be confident that all pre-requisites for learning are present and managed in our registrars. However, experience shows that these are sometimes absent in someone who is underperforming. When the problem lies within these areas, it is likely to be a much greater challenge and have a lower probability of success. If they are not considered or addressed, then failure is guaranteed. This relationship is reflected in Kolb’s Cycle of Learning.

There is a level of assumed knowledge for all doctors. There will be some registrars who have missed core knowledge areas that can influence their performance. Registrars may attempt to hide these knowledge gaps due to embarrassment, or they simply may not be aware of this, so knowledge gaps need to be looked for in those who are underperforming. When significant knowledge gaps are identified, reflection on prerequisites for learning should occur. If no learning concerns are identified, and motivation is deemed to be adequate, it may be that either experience or actual study has been lacking. Identifying knowledge as the key deficit requires an understanding of the cause of the knowledge deficit. The only person who can gain knowledge is the registrar, so they are the ones who need to do the work in managing this area.

These are the individual behaviours that the registrar must perform to be able to act out their roles in a meaningful and effective way. These are not just physical skills such as suturing and taking a blood pressure, but also communication skills and clinical reasoning skills. These are best assessed by watching the registrar perform in their work, rather than from self-reporting. If they are deficient then we must decide:

  • Is this because of a lack of knowledge about the skills?
  • Are they aware of the skill but have never developed it?
  • Have they not had a good role model to see how the skills are meant to work?
  • Do they have the skill but are not using it because they do not perceive this as being valuable or part of their role, or are they not motivated to use it?
  • Or do they not have the confidence to use the skill?

Both knowledge and skills are areas that can be taught and learnt for anyone who has the prerequisites for
learning. Specific strategies are available for each of these.

a. Roles
These are the clusters of behaviours that are expected to be learnt and used in the activity of being a GP. These include being a learner, a communicator, a diagnostician, an educator, and others. Difficulties arise when:

  • There is conflict between expected roles within the job or between roles within the job and outside, e.g., when expected to do after-hours cover and manage the role as a parent.
  • There is too much flexibility in the role. E.g. there may be inadequate guidance from the supervisor or practice about the way a registrar is expected to act or respond in the work situation.
  • There is a lack of role commitment. The registrar does not believe that this is an appropriate role to take on. E.g. They may think that being a listener is not a valuable or reasonable role to perform as a GP.

b. Attitudes and motivation
This is based on the value placed on the activity and the subsequent behaviour by the registrar.
How interested are they in working and behaving in the way they are being directed to? This is influenced by
their belief in the value of the activity as well as by their confidence in their ability to carry out the behaviour.
A registrar who is unmotivated will either openly reject your approaches or accept information tacitly but
with no intention of using the information.

This is the structure in which we practice as a doctor. The computers used, the PBS, the set-up of the surgery and the way a practice operates are examples of the working structure. There may be problems in this area that may be causing registrars to underperform. There may be a lack of understanding about how the system works in a particular practice, or the system itself may be inappropriate or broken, resulting in problems.

This important aspect must always be considered. The physical and mental health of the registrar may have major ramifications in their ability to perform and to change. If the registrar is suffering from some significant underlying emotional or physical illness, then their performance will be significantly reduced. Similarly, if they have a significant family concern, then this will impact on their performance. External demands including financial concerns, travel, relocations, study and separation from family also have an impact on the registrar’s wellbeing and performance. Acting on the other areas witout identifying this as a contributor or priority area will result in sub-optimal interventions and change.

These are the more inherent components of the person that influence their behaviour. They are things that we are born with or develop because of upbringing, family styles or cultural factors and which tend to be less amenable to change. However, this should not be a first label to apply. Other areas should be explored before attributing the difficulty to this area.

This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log

Advertising