A guide to managing performance concerns in general practice registrars

Principles for working with performance concerns in registrars

Last revised: 20 Jan 2025

Having a framework to approach performance concerns in registrars can improve the effectiveness of the medical educator and supervisor, and of the interventions utilised. The following principles are important to consider when working in this space.

A registrar who is underperforming is one who can have significant impact on many people’s lives. Every patient they see is someone else’s mother/father/sister/brother/child. Every patient is part of our community and deserve the best possible health care. Failing to identity and support the registrar in improving means that their patients may be subject to substandard care for the rest of the registrars’ career.

Very few people get up in the morning to say, “I am going to do a bad job today.” Most people approach their work with at least an intention to do things well. Most registrars who are underperforming want to do better. They may be unaware of what they are doing (unknown unknowns) or not sure how to change. This does not mean that we do not address the person about their underperformance. Diane Komp, an American Paediatric Oncologist coined the term “carefrontation” – which is confrontation with care. When there are performance concerns, we are challenging this doctor because we care about them and their patients. It is done with the intention to help.

We have heard the term “premature closure” in consultations. We can do the same when considering performance concerns. As medical educators and supervisors, we must be aware of our own personal biases so that we remain objective and fair when assessing a registrar with performance concerns. Questions to ask ourselves include: Am I too stringent or lenient? What are my pet peeves? Can I be objective with this registrar? Do I have any conflicts that may affect my assessment of this registrar? Do I have enough information to make an assessment? Do I understand the registrar’s point of view? Approaching the issue with genuine curiosity, trying to understand what is happening, and considering many potential causes for the difficulty, helps in supporting the registrar towards change. 

There should be clear lines of communication and clear processes with respect to the documentation of performance concerns and any problems regarding general practice registrars. All relevant discussions and interventions about the identified general practice registrar should be documented contemporaneously. Consideration should also be given to privacy and confidentiality and, consequently, to the levels of access to this documentation and communication among medical educators, general practice supervisors, and regional training team members, regardless of the form of the documentation (paper-based or electronic). Inadequate or insufficient information and poor documentation can make it difficult to enforce processes and regulations when a general practice registrar disputes the issues and is either reluctant or refuses to comply with a planned intervention. With these principles in mind, we can move to an assessment framework. 

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