A guide to managing performance concerns in general practice registrars

Performance management

Last revised: 01 May 2020

Performance concerns in general practice registrars may range from relatively minor, transient concerns to more significant and persistent concerns. They may occur in isolation or, more commonly, in combination, and their presentation may not always be overt but sometimes subtle or disguised. Therefore, depending on the presentation, managing performance concerns in general practice registrars can sometimes be complex. However, most problems and concerns that arise are of a relatively minor nature and are easily managed.

These guidelines will enable Regional Training Organisations (RTOs) to:

  • assess and address the needs of general practice registrars having performance concerns
  • determine the appropriate level of intervention
  • effectively document, manage and evaluate an intervention, including formal remediation.

All RTOs should have documented policies and guidelines in place for managing performance concerns (refer to the RACGP’s Standards for general practice training second edition, Outcome 2.3.3). While the detail of these policies will reflect each RTO’s particular circumstances and structures, there are certain principles that should be followed if performance concerns are to be managed effectively. Policies should:

  • be clear and robust
  • reflect current best practice
  • be available to general practice registrars and other stakeholders
  • ensure patient safety
  • ensure that processes are open, honest and fair
  • be defensible.

The four cornerstones of an effective remediation program are:

  1. the remediation officer
  2. performance reviews
  3. early identification
  4. good documentation.

The key elements of an effective remediation process are:

  • adequate information from multiple sources
  • good communication with all involved, but particularly with the general practice registrar
  • minimal delay with both notification and any action taken
  • impartiality
  • continuous support for the general practice registrar
  • tailored management plans executed in a supportive learning environmen

Performance management process

Figure 1

Performance management process

Appendix A contains a number of case studies that illustrate the dilemmas that can arise when managing performance concerns.

In the practice, performance concerns may be identified through:

  • regular appraisal of the general practice registrar in various situations (eg tutorials, case discussion, random case analysis, discussion of learning needs and progress, direct observation of consultations, review of videotaped consults)
  • feedback from other doctors in the clinic, the practice manager, reception staff and patients
  • feedback from previous general practice supervisors
  • self-identification by the general practice registrar (rare).

At the RTO level, performance concerns may be identified through:

  • the various assessments that are conducted during training, including external clinical teaching visits
  • feedback from general practice supervisors, medical educators, training advisors and administration staff following their encounters with general practice registrars
  • attention and adherence by the general practice registrar to training program regulations and requirements
  • exam failure
  • self-identification by the general practice registrar.

Possible barriers to identification of performance concerns include:

  • inexperience of the general practice supervisor, medical educator or training advisor
  • minimisation of the problem
  • no acknowledgement that a problem exists
  • uncertainty as to whether there is a problem
  • unwillingness to be seen as negative or critical of the general practice registrar
  • unwillingness or reticence to report
  • belief that the problem can be easily managed or will resolve
  • fear of repercussion from the general practice registrar.

Wherever possible, discussion should be held with the general practice registrar to allow them to voice their perspective with respect to any identified concerns. Discussion may also provide a better understanding of the situation, while at the same time motivating and engaging the general practice registrar, in case intervention may be required.

When a concern is raised or a problem identified, the responsible person should be notified. Generally, this should be the remediation officer. Clear processes and lines of communication will avoid delays. Wherever possible, the general practice registrar should be informed that a notification with respect to their clinical performance will be made, not as a punitive measure but in the interests of assisting them to progress in their training.

Possible barriers to notification include:

  • delays in identification and/or reporting
  • unwillingness or reticence to report
  • underplaying of the problem
  • not acknowledging that a problem exists
  • hoping the problem will resolve
  • ignoring or putting up with the problem.

When a performance issue or concern has been raised, the key question to ask is: ‘Does it matter?’ If no, then the general practice registrar may be monitored to observe any other concerns.

If yes, then further information should be obtained to:

  • corroborate what has been reported
  • ensure that as much information as possible is available before any decisions are made.

Further information may be obtained from:

  • the general practice registrar (most importantly)
  • the person notifying
  • anyone who has had direct involvement with the general practice registrar either past or present (general practice supervisors, medical educators, external clinical teaching visit reports, and other staff).

All discussions, but especially those with the general practice registrar, should be done with sensitivity and impartiality because the general practice registrar is likely to be feeling apprehensive and even vulnerable at this point in time.

The next key question to ask is: ‘Can they normally do it?’ If no:

  • ‘Why not?’
  • ‘Are they trainable?’ If yes:
  • ‘Why are they not doing it now?’

It may be necessary to conduct an assessment to further clarify the identified issues and/or to ensure that all the issues have been identified (refer to ‘Problem definition’ below). It is important to have a well-considered approach to assessment. Various assessment methods are available (refer to Appendix C), with the following being particularly valuable:

  • direct observation of consultations
  • review of video-recorded consultations
  • role-play of structured clinical scenarios
  • multiple-choice questions and/or Key Feature Problem (KFP) test.

Following an assessment, feedback (verbal at least but in some instances written as well) should be given to the general practice registrar so that they are aware of and understand the issues. In situations where concerns are of a serious nature, it is feasible to ask the general practice registrar to sign a copy of the written feedback, in acknowledgement of the seriousness of the concerns and that they have been discussed.

The case study in Appendix A (Nidhi) is an illustration of a clinical skills assessment.

Once a performance issue or concern has been raised, another important question to ask is: ‘What else is going on?’

An identified problem doesn’t usually occur in isolation. It is important to look beyond the presenting concern and to identify any other problems that may be contributing, or perhaps may be at the root of the presenting concern. Serious performance concerns do not occur frequently but they do take up a lot of time and resources.

The four broad areas of performance concerns

Figure 2

The four broad areas of performance concerns

Performance concerns can be broken up into four broad areas:

Clinical capability

  • Language and communication skills (verbal, written)
  • Knowledge
  • Application of knowledge, core clinical skills (history-taking, physical examination, investigations, diagnosis, management, procedural skills)
  • Clinical reasoning (ability to interpret and synthesise, decision making)

Health and personal issues

  • Physical and mental health
  • Substance misuse
  • Acute and ongoing problems
  • Personal and family issues impacting on health and/or work performance
  • Periods of transition (changing jobs, moving regions, moving house)
  • A second job

Attitudes and behaviour

  • Professional behaviour
  • Ethical and moral values
  • Personal cultural factors (values, attitudes, beliefs)
  • Insight and self-awareness, intuitiveness and ‘sixth sense’
  • Confidence

Work environment and systems

  • Work and work environment (workload, interaction with general practice supervisor and practice staff, teamwork, bullying, harassment, discrimination)
  • Systems (training and practice regulations, working hours and rosters, employment contract)

Possible errors with problem definition include:

  • insufficient information
  • incorrect or misleading information
  • assumptions made
  • inappropriate decisions
  • a lack of objectivity
  • preconceived ideas and bias
  • an ill-considered approach.

In defining the problem/s, there are five key questions to consider:

  1. Is the general practice registrar practising safely?
  2. Can the general practice registrar reason (problem solve) effectively?
  3. Is the general practice registrar practising to a satisfactory standard?
  4. Does the general practice registrar behave professionally?
  5. Does the general practice registrar have insight?

The first three questions relate directly to the general practice registrar’s level of clinical knowledge and skills, the standard of their practice and whether they have the capability to improve.

The fourth question relates directly to the general practice registrar’s behaviour towards patients, colleagues and staff, and their behaviour in general. It has indirect implications for clinical practice.

The fifth question relates to the general practice registrar’s awareness of their limitations and deficiencies in their knowledge and skills, and their ability to accept feedback. It has direct implications on patient safety and willingness to learn and change.

In order to answer these key questions, the general practice registrar’s clinical performance needs to be looked at more closely. The following questions pertaining to specific skills and behaviours provide a useful framework.

Specific skills and behaviours

Communication skills

Does the general practice registrar:

  • communicate effectively (language, verbal and non-verbal skills)?
  • develop rapport and show empathy?

Clinical skills

Does the general practice registrar:

  • demonstrate a sufficient level of clinical knowledge and skills?
  • recognise urgent situations and respond appropriately?
  • prescribe appropriately?

Cognitive skills

Does the general practice registrar:

  • synthesise information and problem solve appropriately (clinical reasoning)?
  • recognise their limitations (reflective skills and insight) and seek appropriate advice and/or assistance?

Organisational skills

Does the general practice registrar:

  • have a structured approach to the consultation?
  • manage their time appropriately?
  • record the relevant medical notes in a timely manner?
  • work effectively in a team (staff and health professionals within and outside the practice)?

Professional behaviour

Does the general practice registrar:

  • behave professionally (including being non-judgemental)?
  • accept and reflect on feedback?

In accordance with the above framework, Table 1 in Appendix B provides a guide with respect to what observations would raise concerns. Answering these questions is useful not only in providing a sense of the adequacy of the general practice registrar’s consulting, but also for providing the general practice registrar with constructive feedback for improvement.

If the answer to one or more of the key questions is ‘no’, then the concerns are serious and the RTO remediation officer should always be involved in such instances.

Serious concerns (‘red flags’)

It may be that serious concerns have already been identified. Table 2 in Appendix B is a checklist of serious concerns. Identification of one or more of these requires urgent reporting to the RTO’s remediation officer and director of training. How these concerns will be addressed will depend on the context. Mandatory reporting to the Australian Health Practitioner Regulation Agency (AHPRA) may be necessary; however, this can only be done when there is direct evidence of practitioner impairment and/or risk to patient safety.

Applying analytic rigour to judgement and decision making

Every medical educator has an individual approach to conducting an assessment and certainly when making judgements and decisions. It must also be acknowledged that everyone has personal biases, therefore it is important to be objective and fair. In order to do this as best as possible, the following should be considered:

  • Reflect on personal biases
    • Am I too stringent or too lenient?
    • What are my pet likes/dislikes?
    • Is there something about the general practice registrar that I like/dislike?
  • Have I ignored information or certain observations?
  • Is there any information that refutes certain judgements that I have made?
  • Are my judgements explainable by the observations that I have made? If not, what information is missing?
  • Is there information from other sources (including the practice) that supports or refutes my judgements?
  • What is the general practice registrar’s opinion about their performance and my judgement?
  • How adequate was this assessment? Was it sufficient to make the judgements that have been made? Is further information and/or assessment required?

Once the performance concerns have been defined, the general practice registrar may require one of the following outcomes:

  • monitoring
  • assistance through implementation of a focused learning intervention
  • assistance through implementation of a formal Remediation Plan.

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:

  1. 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).
  2. 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).

Any management plan should have provision for periodic assessment during the execution of the plan and certainly at its completion. At completion, the outcomes of the intervention will be evaluated, to determine whether the objectives have been achieved and what this means with respect to the general practice registrar’s progression in the training program.

A list of suitable assessment methods is found in Appendix C.

Measuring progress or change can be difficult but should be as objective as possible and have consideration for the expected standard for the general practice registrar’s level of training (benchmarking).

When evaluating a management plan, the key questions to ask are:

  • Is the general practice registrar progressing?
  • Is progress sufficient?
  • Is the general practice registrar capable of achieving the expected clinical standard?
  • What resources are required to assist the general practice registrar to achieve the expected standard?
  • Should the general practice registrar continue to be supported?

If improvement has been ‘insufficient’, the reasons why should be determined.

These include:

  • the general practice registrar themselves (eg poor engagement, learning difficulties, inability to progress because of unresolved personal or health issues)
  • the general practice supervisor or medical educator (eg inadequate/insufficient support)
  • the management plan used (not well formulated, inadequate resources, insufficient time frame).

After an evaluation has been made, the following actions are possible:

  • the general practice registrar will be allowed to resume training under any of the following conditions
    • without additional support
    • with a focused learning intervention in place which will enable them to reach the required level of training
    • with placement in a remedial term
  • the general practice registrar will be excluded from general practice training (refer to the AGPT Withdrawal Policy) because
    • the identified problems have not improved sufficiently and the general practice registrar is not expected to reach the required level of training even with additional support
    • the identified problems have not improved at all.


General practice registrars who oppose the need for remediation as determined by their RTO may access the RTO’s appeals process to review the matter.

Where the RTO determines that remediation has failed and further remediation is unlikely to be successful and where the general practice registrar disputes the RTO’s decision, the general practice registrar has access to the following mechanisms for appeal:

  • the RTO’s grievance and appeal procedures for review and mediation
  • applying to the RACGP for a review of the RTO’s decision, but only after the RTO’s avenues of appeal have been exhausted – refer to the RACGP’s Registrar Clinical Appeals Policy.

Monitoring is an important aspect of managing performance concerns. While many concerns will be of a minor nature and easily resolved, the general practice registrar’s progress should be monitored because the initial concern may escalate or new concerns may arise. Monitoring also ensures that concerns aren’t forgotten, only for them to resurface later, potentially as major issues. It also allows for minor interventions to be put into place along the way, hopefully preventing escalation of problems.

The remediation officer is best placed to monitor identified general practice registrars. Monitoring involves regular contact with the general practice registrar, general practice supervisor, medical educators and others, as appropriate.

Possible outcomes of monitoring include:

  • resolution of the problems/concerns
  • the problems/concerns have become more serious and intervention is required – the situation then has to be reassessed and a management plan formulated.

The reasons a general practice registrar might leave the training program include:

  • temporary leave for personal or health reasons
  • permanent leave for personal or health reasons
  • removal from the program because of a serious performance concern. This will generally be because of
    • failure to progress despite remedial intervention
    • a serious breach of professional behaviour.

When a general practice registrar indicates that they wish to return to training, having been absent from the program for a substantial period of time (longer than 12 months), a number of things need to be taken into consideration:

  • the period of absence
  • the registrar’s level of confidence with respect to returning to work and what supports might be helpful
  • any unresolved concerns (clinical skills or otherwise) that existed prior to the registrar leaving
  • the possibility that the registrar’s clinical skills may have deteriorated during their absence
  • any new concerns that may have arisen during the registrar’s absence, such as personal or family issues, illness or disability, and the ensuing implications for clinical practice, such as
    • accommodations that may have to be made
    • supports that might be required
    • any conditions that may have been imposed by AHPRA on the registrar’s practice.

A clinical skills assessment may also be appropriate to determine what assistance, if any, the registrar might require to ensure a smooth transition back into practice.

AHPRA has its requirements with respect to doctors re-entering practice, particularly when that absence has been for longer than 36 months. Those requirements are essentially with respect to:

  • recency of practice
  • continuing professional development
  • professional indemnity standards.

More information can be found on the AHPRA website or in the RACGP document, A guide for re-entry to general practice

Passing the RACGP Fellowship exam should not be viewed as an easy exercise. Preparation is necessary and registrars should be encouraged to commence preparations earlier rather than later. Failure can easily occur and results in significant distress for the registrar.

On its own, first failure is not necessarily concerning. While there are many possible reasons for failure, they are generally easily addressed and the general practice registrar will, more than likely, pass at the next sitting. The reasons generally relate to the general practice registrar’s:

  • particular circumstances (personal and family issues, health problems)
  • limited exposure to a sufficient range of presentations (including chronic disease)
  • approach to study.

For a small number of general practice registrars, the exam presents a significant obstacle. Once again, there are many possible reasons why this might occur. Sometimes, the reasons for failure may not be immediately apparent, may not have been considered previously or may be deep seated. Second and subsequent exam failures therefore, should be taken seriously and the possible reasons for failure should be explored thoroughly:

  • clinical knowledge
  • clinical reasoning
  • clinical practice
  • exam technique
  • study
  • other factors (including health and personal).

Using this information, a Learning Plan to preparing for the next sitting may be formulated. For more specific guidance, refer to ‘Exam support guidelines’ in A guide to understanding and managing performance concerns in international medical graduates.

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