Principles for managing performance concerns

It is important for the IMG to be engaged, from the outset, when concerns are first identified, and certainly in the formulation of a management plan. It is helpful to:

• try to understand the IMG, their background, and their personal and life issues
• consider their side of the story: What do they perceive are the issues/difficulties? What do they believe they need help with?
• maintain awareness for any issues or needs that are unspoken.

It may be necessary to conduct an assessment (direct observation and/or video with feedback) when it is not clear what the precise concerns are. All issues at play should be identified, not just the clinical skills concerns. Remember, it’s not all ‘knowledge gaps’ and ‘cultural’. There may be underlying contributing factors, such as personal health, family or even industrial relations problems. Only once these have been considered and explored can the fundamental issues (causative factors) be truly discerned.

Lastly, in discussion with the IMG, it is important to agree on the management plan:

• issues that need to be addressed and the objectives
• medical educator and supervisor support
• educational strategies/activities – help the IMG understand that didactic teaching is not always the best method
• time frame for implementing the plan
• how progress during implementation of the plan will be assessed
• how outcomes will be evaluated upon completion of the plan.

In formulating a management plan, including a learning plan, it is important to consider conflicts that may occur between educator and learner expectations. Generally, the learning methods preferred by IMGs are:

• procedural teaching
• case-based discussion
• exam-oriented teaching
• interactive lectures/tutorials
• Applied Knowledge Test/Key Feature Problem (AKT/KFP) quiz sessions.

The methods of learning least preferred by IMGs are:

• reflective writing
• small group learning (webinar format)
• role-play
• critical analysis
• random case analysis/discussion
• direct observation and videorecording of consultations.

IMGs may feel threatened by direct observation, videorecording of consultations and role-play. Rather than seeing these as learning opportunities, they may perceive them as tests of their capability that may result in them being unable to practise or, possibly, being reported to AHPRA.

In regard to learning, educators place emphasis on:

• depth of learning and understanding
• learning that lasts (that is retained and built on)
• lifelong learning (CPD).

Educators also have expectations that the learner be motivated to learn and put what is learnt into practice.

Learners, however, may appear to be more concerned with:

• surface learning
• wanting to pass exams
• learning to the test.

On face value, therefore, there is a mismatch between what the educator believes is good for the learner and what the learner wants. It is important not to lose sight of the ‘greater picture’, which is to develop clinical skills and become a competent GP with the capability to practise safely and independently anywhere in Australia (which is the assessment standard for the FRACGP exam). Study that focuses purely on passing the exam is unlikely to bring the desired results.

In all instances, the following factors are key for habits to change and improvement to occur:

• attitude (willingness to change)
• motivation (desire to change)
• discipline and determination
• a well-considered study plan.

Even though IMGs are required to pass an English language test before working in Australia, some, in varying degrees, experience language difficulty quite separate to any difficulties with communication skills. Strategies for improving language skills include:

• formal English lessons
• English language coaching from a speech therapist or linguist – this is useful when the IMG has a strong accent, difficulties with pronunciation or makes syntactical errors
• self-help:
  • speaking a little more slowly, loudly and clearly
  • support from family and friends
  • networking and speaking English with other IMGs
  • more contact with everyday spoken English (listening to radio and news, reading newspapers, watching Australian TV programs where everyday language is used, watching English-language medical programs)
• practice, practice, practice!

Support from family and friends may be in the form of encouragement to improve language skills but it could be as simple as talking to the children at home or trying to explain something medical to a family member or friend. Children pick up language a lot more easily than adults and they can be very good at correcting errors in vocabulary, use of idiom and even the nuances of language. Someone who doesn’t have medical knowledge is best placed to give feedback on whether they clearly understood medical information that was conveyed to them and whether the manner in which it was conveyed was engaging.

It is important for the IMG to understand the fundamentals of Australian general practice. Generally, this teaching can be incorporated in clinical skills tutorials. However, when the IMG does not have a good understanding, it may be necessary to conduct specific sessions on:

• the general practice environment and culture
• the doctor–patient relationship and patient-centred care
• teamwork and interpersonal skills within general practice.

When teaching clinical skills, the following are important aspects of these skills to be mindful of.

• Communication skills:
  • using verbal, non-verbal and written communication
  • ensuring two-way communication between doctor and patient
  • building rapport
  • understanding the patient and being understood by the patient
• Having a structured consultation
• History-taking:
  • regularly checking the accuracy of gathered information with the patient
  • summarising, so as to ensure all the relevant information has been gathered and understood
  • gathering sufficient evidence that supports/refutes the working hypothesis
  • considering the possibility of any serious underlying issues (red and yellow flags, Murtagh’s ‘masquerades’)
• Physical examination:
  • conducting a focused physical examination
  • gathering evidence that supports/refutes the working hypothesis
  • considering new/unexpected findings in relation to the presentation
• Clinical reasoning (problem solving and formulation of hypotheses):
  • not relying on illness scripts alone
  • understanding the difference between a diagnosis and a working hypothesis
  • keeping an open mind and creating a shortlist of working hypotheses, rather than focusing too quickly on a single hypothesis or diagnosis
  • giving due weight to findings, relative to the presentation and relative to the working hypothesis
• Management:
  • prioritising the problem list and thinking in terms of short-, medium- and long-term management
  • considering the urgency of certain situations and responding to that urgency
  • creating structured management plans
  • tailoring management plans to the individual, including negotiation with the patient to agreed outcomes
  • delivering management plans effectively and confidently and giving clear instructions
  • providing information and explanations in a clear and concise manner and tailoring to the patient context
  • using shared decision making
  • safety netting

With respect to providing information and explanations fluently and effectively, one useful way of becoming more practised is for the IMG to pick a topic from Murtagh’s Patient education, learn it and then say it out loud using their own words. There are several ways in which this may be done:

• talking to a mirror
• audio recording and playing back, and repeating this until they not only ‘get it right’ but feel more comfortable saying it
• saying it to a relative or friend who can give them feedback on how it was said but also on whether they understood the information.

Educational strategies include:

• creating opportunities to engage with mentors, coaches and supervisors, wherever possible
• direct observation and feedback (it is important for the educator to clarify that their role is supportive and the aim is to assist the IMG’s learning and improve their skills)
• videorecording and feedback (as with the direct observation, it is important for the educator to clarify what their role is)
• sitting in with an experienced doctor to observe their clinical skills but also to obtain a clear picture of Australian general practice
• role-playing and discussion of a variety of clinical presentations, including more challenging ones, to:
  • develop self-confidence and assertiveness (taking control of the consultation and being decisive)
  • improve the overall structure of consultation, information gathering and management plans
• case discussion (including random case analysis) with emphasis on clinical reasoning
• case presentation with emphasis on presenting the information in a structured way, using language that is appropriate for peer-to-peer interactions.

The general principles of giving effective feedback should always be followed, no matter the context. The following points merit highlighting:

• be mindful of the IMG’s perceptions of feedback, address any misconceptions and be clear about your intentions
• be mindful of the IMG’s reactions to the feedback 
• give specific examples of what was done well and what requires improvement
• give clear explanations as to why something should be done differently or requires improvement 
• suggest alternative ways of saying/doing something.