Why we need remote supervision of GP registrars
There is an urgent and increasing need throughout Australia to build and sustain the rural and remote GP workforce. Approximately 29% of the Australian population lives in rural and remote areas, where the ageing population has a higher mortality and morbidity rate due to chronic disease, multimorbidity and injury.
In 2013, Australians had access to 274 doctors per 100,000 in remote/very remote areas, compared with 433 doctors per 100,000 in major cities.1
It has been well established that the total disease burden in rural and remote areas is higher, with poorer health outcomes, more barriers to accessing healthcare and a greater reliance on GPs to provide a wider scope of services.2 There are fewer GPs in outer-regional, remote and very remote locations, with the percentage of GPs choosing to work in rural and remote Australia declining.3 This is even more pronounced in remote Aboriginal and Torres Strait Islander communities, where the increased burden of disease means there should be more doctors per head of population, as well as an increased availability of longer consultations.4
The patients in these areas often have limited access to safe and timely local medical services. Even when there is a doctor present, many new doctors who are working in rural and remote areas have little previous experience, current oversight, appropriate qualifications or support for the work they are doing.5 Local GPs may be overloaded with their own clinical practice and not have the time or enthusiasm to supervise a GP registrar, with many close to burnout. Access to primary healthcare services ensures that prevention, early intervention, continuity of care and managing chronic health needs are addressed.
Providing training in these settings is essential to develop GPs with relevant skills for the scope of practice required by regional, rural and remote communities.1 Those who are trained in such areas of need are more able and willing to continue to work there after qualification and will fill a need in many areas during their training.
In the Northern Territory, registrars play a particularly vital role in the provision of primary healthcare in remote areas. In addition, the future success in closing the gap in Aboriginal and Torres Strait Islander health outcomes is heavily reliant on a well-coordinated and well-supported general practice workforce and training system.
Remote supervision of GP registrars has been occurring in pockets of Australia for many years using diverse models. Although educators may be anxious that remote supervision is not as safe, there is no evidence of harm with remote compared with onsite supervision.6 Good remote supervision may be better than poor onsite supervision, and is definitely better than no supervision.5
There is evidence that a well-supported model designed specifically for remote supervision ‘facilitates the creation and maintenance of professional connections and support’.7 The use of telehealth, such as videoconferencing, email, telephone and remote access to patient information, and even patients themselves, can also alleviate the time, cost and resources required to supervise a registrar remotely in a remote situation compared with face-to-face supervision.
Supervision involves providing monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the registrar’s care of patients.5 This would include the ability to anticipate a registrar’s strengths and weaknesses in particular clinical situations in order to maximise patient safety.5
Good supervision is based on a strong educational alliance that is much more than just clinical advice. The presence of a supervisor does not necessarily lead to good supervision; this requires a ‘sound professional relationship, self and mutual awareness of strengths and weakness, confidence to seek and provide help at any time, and the ability to provide and receive appropriate feedback’.8
In an effective remote supervision model, the registrar is supervised not only by their designated supervisor, as would mostly occur in a mainstream urban practice, but also by a team, which may include the Aboriginal health worker/practitioner, practice manager, nurse, local tertiary services and other multidisciplinary community-based health services. This not only expands clinical knowledge, but also builds up an ‘amalgam of role models and richer learning than interaction with a single supervisor’.6
In Australia, ‘rural generalism’ is a broad term encompassing practice in rural and remote areas. Ensuring that GP registrars are effectively supervised in order to develop rural generalism skills has proven difficult in many areas, and remote supervision may be an essential strategy to ensure the future rural generalism workforce is maintained.
Generalism is a philosophy of care that is distinguished by a commitment to the breadth of practice within each discipline and collaboration with the larger healthcare team, in order to respond to patient and community needs … Generalists diagnose and manage clinical problems that are diverse, undifferentiated, and often complex. Generalists also have an essential role in coordinating patient care and advocating for patients.9
Rural generalist training involves not just knowledge and skill development, but also the development of wisdom, and is best done in collaboration with the local community.10
Flexibility is needed to contextualise the specific requirements of the practice and community with the skills of the registrar and supervisor. A process for tailoring and evaluating the needs and outcomes for the registrar, supervisor, practice and patients will ensure that the diversity of people and environments are well matched, and outcomes are safe.
Patient needs
The more nuanced aspects of training in isolated remote Aboriginal and Torres Strait Islander communities and other disadvantaged groups can only be learnt ‘on the ground’. This will include the interdependent relationship between a patient’s illness and their psychological, biological, social, economic and cultural circumstances. These factors can influence the presentation of an illness, the doctor–patient relationship, engagement with investigations, expectations, management and recovery.
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Registrars who are remotely supervised are responsible for promptly finding evidence-based and contextually appropriate answers to problems, which may mean contacting the remote supervisor, other members of the supervision team or seeking help on the internet or in textbooks. Research has shown that patients often prefer this approach to a long wait for a visiting specialist or travelling away from their homes to a distant hospital.
6
There is concern that patients may not be comfortable consulting a remotely supervised registrar rather than a more experienced GP. However, research has shown that, from the patients’ perspective, receiving care from a junior doctor who respects their autonomy, uses an interpreter, is explicit about their level of experience and is remotely supervised via videoconference may be more ‘safe than transfer to an expert who works in the alien environment of a large teaching hospital’.
5
There is a perceived increase in the quality and continuity of healthcare resulting from more trainees working in the community, rather than an ever-changing supply of locums … Therefore, there is improvement, not only in overall health status and outcomes, but also specifically to accessibility, continuity and quality of healthcare, including preventive healthcare services, and the availability and sustainability of the rural GP workforce.
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Supervisor needs
There is a balance that needs to be reached for effective supervision between the level of support for the registrar and the challenges they confront. Giving appropriate feedback and promoting reflection on a background of a strong educational alliance will ensure that it is safe for the registrar to ‘reveal and address weaknesses in his or her knowledge, skills and emotional responses to practice’.
5 Attending to the registrar’s wellbeing, supporting them through challenging situations and brokering their relationship with the practice and the community are also essential elements of the supervisor’s position.
GPs choose to take on a role as a supervisor for various reasons, such as altruism, an interest in improving general practice quality, increasing the general practice workforce, sharing values and knowledge and believing teaching to be part of a GP’s role.
13 Teaching also improves morale and increases professional support and the sense of collegiality.
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Whatever form remote supervision takes, it should facilitate learning, ensure patient safety and help the registrar in their development of professional identity. Continuity of the supervisor allows for the development of a relationship of mutual respect and trust, which will facilitate discussions about any personal issues, vulnerabilities and dilemmas that ‘go to the heart of being a health professional’.
5
As the GP population ages over the next 10 years, many GPs may be looking for flexibility, such as part-time teaching along with their clinical work, particularly in order to reduce their risk of burnout. Such a move may prevent their early retirement and ‘loss of their wisdom’ from general practice’.
14 Others may be interested in providing locums in rural areas or doing telehealth along with fly-in, fly-out (FIFO) work.
Accessing GPs who are willing and able to take on a role as a remote supervisor may mean targeting those senior clinicians with rural, remote and contextualised experience and interest who may otherwise be retiring and completely lost to general practice. There is already some literature outlining how ‘gaps in the ability of local staff to provide clinical supervision would be supplemented … to create a supervision team with local contextual and subspecialty expertise’.
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GP registrar needs
It has been found that registrars who are remotely supervised are more resourceful in seeking answers to their clinical questions,16 receive feedback on clinical decisions they have made autonomously,5,17 learn how to cope when immediate advice is not available and develop skills that will assist them with practising independently as a Fellowed GP.18 A period of remote supervision is expected to help bridge gaps in preparedness by demonstrating to registrars what else they need to learn for competent, independent practice at a stage when they still have access to supervision and support.5
Providing remotely supervised registrars are not overwhelmed by the responsibility, there is an argument supported by the literature that learning occurs best with remote supervision, because remotely supervised registrars are likely to be working at the limits of their confidence and ability. For instance, those who have supervisors nearby may ask for assistance without going through the full process of problem solving and clinical reasoning.5−7
In addition, remote supervision will increase opportunities in rural and remote communities, where the scope of practice will be increased, not only adding to a registrar’s clinical learning, but also contributing to their professional and personal resilience and increasing their professional confidence.1
Finally, a quality orientation program, the support and advice of the local team, being embedded in the organisation and their integration into the community widens a registrar’s professional and social learning even more in other domains outside clinical medicine. Although the learning opportunities in remote supervision are enhanced in comparison to onsite supervision, the experience must be underpinned by a clear registrar support program. Without ample opportunity for reflection, networking and/or peer support, there is a risk of isolation that will jeopardise both the registrar’s learning and the likelihood of them being retained in remote locations.19 Indeed, compulsory rural placements have been shown to be a negative experience for many registrars and to be unlikely to increase the future rural workforce.20
Evaluation of the success of remote supervision will include assessments of processes, the training and the safety. However, the real success will be seen when registrars stay in the community after completion of training, or recommend that their colleagues train with remote supervision.