Once the issues have been defined, a management plan (which will include a Learning Plan) should be drawn up. Most management plans will address clinical capability. Concerns that exist in other areas should also be addressed and included in the management plan.
Management plans should always:
- be developed in consultation with the general practice registrar
- be personalised to the general practice registrar’s needs
- have clear objectives
- have a set timeline, with regular reviews and a clear end point
- have provision for reassessment and evaluation of the outcomes
- have defined actions with respect to the outcomes.
There are two types of management plans:
- Focused learning interventions address identified problems that can be readily corrected in the normal course of training using available resources (refer to ‘Clinical capability’ below).
- Formal Remediation Plans are required when serious performance concerns are not expected to be readily corrected in the normal course of training and where previous focused learning interventions have not succeeded.
5a. Focused learning interventions
Clinical capability (clinical knowledge and skills)
A variety of clinical skills interventions is available; however, the following points require highlighting:
- The type of intervention will depend on the cause of the performance concern. If the root cause is not addressed, the general practice registrar will not progress.
- A well-considered, tailored management plan that addresses all the issues at play is more likely to be successful.
- Determining the learning style of the identified general practice registrar may be helpful.
- The learning environment must be supportive.
- The general practice registrar needs to be fully engaged.
Possible interventions for addressing deficiencies include:
- tutorials to address knowledge deficits
- case discussion, including random case analysis
- direct observation of consultations with feedback
- review of video-recorded consults with feedback
- role-play of a variety of clinical scenarios.
Health and personal issues
General practice registrars may become ill like any other individual. Any significant illness, whether physical or mental, acute or ongoing, has the potential to:
- affect the general practice registrar’s judgement or performance
- impact on patient care
- impact (to varying degrees) on self, family and friends, colleagues, and work capability.
Chronic illness and disability is not a contraindication to clinical practice. While allowances and adjustments can be made so that the general practice registrar may function to the best of their ability, patient safety is always paramount.
The more common health problems affecting performance are:
- psychological disturbances (eg depression, anxiety)
- unhealthy lifestyle, including substance misuse.
The stress of daily medical practice should not be underestimated. For general practice registrars coming out of hospital practice and entering general practice training, there is a significant adjustment and much to learn in their first term. It also takes time to settle in to general practice, particularly for part-time general practice registrars. Anxiety, therefore, is not uncommon for general practice registrars.
When a clinical capability problem has been identified, consideration should be given as to whether a concurrent health issue exists and procedures should be in place for identifying and managing a general practice registrar with health issues. While enquiry about health issues is appropriate, it should be motivated primarily out of concern for patient safety and also for the welfare of the general practice registrar. Sensitivity should be exercised, as well as care, to comply with anti-discrimination and privacy legislation. The general practice registrar should be encouraged to evaluate their situation objectively and to consider whether patient safety might be compromised. It is not appropriate for a medical educator to take on the role of treating doctor or therapist with respect to the registrar. The educator’s role can only be advisory.
General practice registrars with a health problem should be encouraged to seek appropriate care from a health professional (their own GP, treating specialist or psychologist). It may also be appropriate for them to take leave from training in order to adequately address their health issues. Refer to the Australian General Practice Training (AGPT) Program Leave Policy.
Where a serious or ongoing concern exists, to the extent that patient safety is being compromised, consideration will have to be given as to whether it is necessary to report the general practice registrar to AHPRA. If the general practice registrar is reported, the RTO must ensure that:
- the decision of the relevant Medical Board is implemented
- the Department of Health is informed of the Medical Board’s decision.
If the general practice registrar does not comply with the Medical Board’s decision or is unlikely to regain their fitness to engage in general practice training, then the general practice registrar may be:
- required to take leave from general practice training until such time they are well enough to return, or
- excluded from general practice training (refer to the AGPT Withdrawal Policy).
Attitudes and professional behaviour
Unprofessional behaviour can have a significant impact on the general practice registrar’s functioning in the workplace, as well as the functioning of that workplace. RTOs are encouraged to have a professional behaviour policy in place that:
- identifies the expected professional behaviour
- identifies the possible consequences of unprofessional behaviour
- supports the development and maintenance of a culture of professionalism within the organisation and throughout training time
- is committed to the early identification of, and response to, professional behaviour problems
- provides suitable mechanisms for monitoring and addressing problematic situations
- provides suitable mechanisms for addressing serious and/or continued breaches of professionalism.
Without such a policy that identifies the expected behaviour, including the consequences of serious and/or continued breaches of professionalism, it will be very difficult to manage the concerns effectively.
Refer to the RACGP’s Standards for general practice training second edition (Outcome 3.1.2) and Competency profile of the Australian general practitioner at the point of Fellowship for more information.
Work environments and systems
Work environment and systems issues have the potential to indirectly precipitate a deterioration in performance either on their own or in conjunction with other problems. Resolution of these issues will generally occur by:
- face-to-face discussion between the disputing parties
- a formal mediation process
- seeking legal advice.
5b. Formal remediation
Formal remediation will be required for general practice registrars:
- whose clinical capability does not improve, despite the implementation of a suitable focused learning intervention
- who have a serious performance concern from the outset.
The Remediation Plan must be developed by the remediation officer in consultation with the general practice registrar, the remedial general practice supervisors, remedial medical educators and the director of training, as required. The plan should be documented in a formal Remediation Agreement or contract that also specifies:
- the requirements
- the role of each party to the agreement/contract
- the time frame for the remediation, which should not exceed six months
- the objectives of the remedial term
- the possible outcomes
- how the outcomes will be evaluated
- the action that will be taken with respect to the outcomes.
A template for a suitable Remediation Agreement is found in Appendix D.
A formal remedial term requires a suspension of training time for the duration of the remedial term and must be recorded as such in the general practice registrar’s training record.
An application can be made to the RACGP for funding to support the extra resources that will be required for the remediation. Funding must be approved first before the remedial plan can be enacted (refer to the RACGP’s Registrar Remediation Policy).
Processes should be in place to identify general practices and general practice supervisors that are suitable and willing to take the general practice registrar for remedial training.
In circumstances where the RTO cannot accommodate remediation within its region, a transfer to another location may be appropriate. Refer to the AGPT Transfer Policy, Item 6.1.1.
If a suitable remediation placement cannot be sourced at all, the general practice registrar may be required to take leave until an appropriate remedial placement can be found (refer to the AGPT Program Leave Policy).