The four cornerstones

Ultimately, there should be one person responsible for overseeing performance concerns in general practice registrars to ensure that processes are being followed, and that performance concerns are identified and addressed.

The remediation officer’s role is to:

• investigate concerns – this initially entails talking to the general practice registrar and to those who have knowledge of the situation or who have had contact with the general practice registrar (in present and previous general practice terms)
• advise and assist medical educators and general practice supervisors who have concerns
• assess concerns and take appropriate action
• determine the appropriate intervention and who should be involved
• delegate responsibilities appropriately
• formulate or assist in the formulation of a suitable intervention
• liaise with all parties involved in an intervention (the general practice registrar, medical educators and general practice supervisors) to ensure that everyone is well informed about and in agreement with the proposed plan, including its outcomes
• monitor all general practice registrars with performance concerns
• periodically review and/or assess identified general practice registrars
• assist medical educators and general practice supervisors in reviewing the progress of general practice registrars receiving extra assistance
• decide if the support/assistance being given to a general practice registrar needs to be continued
• document all information (concerns, actions taken, decisions made) regarding identified general practice registrars
• periodically liaise, as appropriate, with key individuals regarding the general practice registrar’s progress and any decision making
• facilitate the lines of communication between anyone directly involved in the general practice registrar’s learning and those who need to be informed
• regularly review guidelines and processes with respect to performance concerns so they are up to date and reflect best practice.

All general practice registrars should have performance assessments conducted on a regular basis during their training – refer to the RACGP’s Standards for general practice training second edition, Standards 1.1, 3.1 and 3.2. Performance assessments should be conducted:

• just prior to, or soon after, commencing training
• at appropriate stages during training.

Performance assessments are used to:

• determine each general practice registrar’s particular needs
• monitor and assess progress
• identify performance concerns as early as possible
• enable the early enactment of suitable interventions when required.

A range of assessment methods is listed in Appendix C of this guide.

A formal review of the progress of all general practice registrars should be conducted each semester:

• by the general practice supervisor in the practice
• at the RTO level.

Performance reviews will consider information from such sources as:

• the general practice registrar’s learning needs and other assessments
• feedback and reports from general practice supervisors, medical educators and training advisors
• external clinical teaching visit reports
• feedback and reports from the remediation officer.

The earlier a performance concern is identified, the more likely an intervention will result in positive outcomes. Low-level problems may not seem significant enough individually to be reported, but several such problems, possibly in different areas, may cause sufficient concern to require action. It is preferable to report an identified problem or concern promptly, rather than wait to see if it will persist or escalate. The remediation officer should be the person to determine the level of concern, the appropriate action and the urgency required.

Early identification and reporting of problems is encouraged and may be facilitated by:

• informing general practice supervisors and increasing their awareness about general practice registrars at risk – general practice supervisors are in a key position to identify problems because of their regular contact with the general practice registrar
• informing medical educators and increasing their awareness about general practice registrars at risk
• encouraging prompt reporting of problems
• conducting learning needs assessment at the commencement of training
• directly observing the general practice registrar (by the general practice supervisor or an external clinical teaching visitor) early in the first general practice term or early in subsequent general practice terms when concerns have been raised.

The following is a checklist of the types of concerns that should be reported.

• Communication skills
  • comprehension issues (hearing, understanding)
  • poor rapport
  • serious lack of empathy
• Clinical skills
  • significant knowledge deficiencies
  • inadequate clinical skills
  • serious clinical errors and safety concerns (eg misdiagnosis, mismanagement)
  • unorthodox or dangerous prescribing
• Cognitive skills
  • disorganised or rigid thinking processes
  • not seeking advice or asking questions as expected for their level of training
  • seeking assistance excessively and/or for seemingly minor things
  • rigidity in their role and their opinions (eg poor tolerance of ambiguity, difficulty prioritising, inability to compromise, being argumentative)
  • lack of insight
  • difficulty reflecting
  • difficulty accepting feedback, defensiveness
  • inability to change, difficulty acting on feedback that has been given, poor progress (despite feedback, past experiences and learning)
• Organisational, integrative and collaborative skills
  • poor interpersonal skills (paucity of interactions or negative interactions with colleagues and practice staff, anger outbursts, believing that they are victimised)
  • poor (unjustified) time management for the level of training
• Professional behaviour
  • unprofessional behaviour
  • poor work ethic
    • frequently arriving late and/or leaving early
    • absences (eg frequent and/or unjustified)
    • poor work performance (eg deliberately slow, blocking out appointment times)
    • deliberate overbooking of patients
  • not accepting responsibility for the patient
  • teaching and learning
    • poor attitude to teaching
    • not proactive with respect to their learning
    • late with submission of tasks
• Other
  • overt signs of impairment (eg mental illness, substance misuse)
  • serious complaints from staff, patients and others.

Refer to Table 2 in Appendix B for a checklist of ‘red flags’.

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 among medical educators, general practice supervisors, RTO staff and management, regardless of the form of the documentation (paper-based or electronic).

Communication of important information to key individuals in the performance management framework is vital but, once again, this needs to be weighed against considerations of privacy and confidentiality.

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.