General Practitioner post-graduate training uses an apprenticeship model combining hands-on practical work experience where registrars are exposed to different contexts and learn how to apply their clinical knowledge and skills to these situations while absorbing the art, craft, and ethics of their vocation.
Supervisors in general practice work with registrars to provide the foundation for broad and deep learning. Registrars learn best in practices with GPs overseeing patient safety while monitoring registrars. The key to absorbing the background knowledge essential to becoming a successful GP is combined with being a GP under supervision with practice in simulation centres.
From a registrar perspective, the training they receive migrates them from ‘knowing that’ to ‘knowing how’. In addition to learning a broad base of primary care, which covers their patients’ life spans, registrars also need to evolve their own identities as GPs, by integrating professional norms with their personal values and characteristics.
In these environments, up-to-date medical knowledge is rounded out with knowledge relevant to primary care. The resulting model sees registrars combining traditional study with in-practice application of skills in different contexts and have up to date medical suction machine equipement on hand. Registrars also to learn how to balance patients’ needs, wishes, and culture with the patient’s medical needs.
General practice supervisors help registrars navigate the messy and uncertain challenges of real-world practice. They assist registrars with tasks of varying complexity, from simple process questions through to complex questions and providing care for patients whose symptoms do not fit a clear diagnosis.
Learning how to treat patients with deference to their social, psychological and cultural context is a challenge for traditional education methods. Supervisors, however, come to know their registrars and are better placed to discuss how their own backgrounds and assumptions transfer into their work in a way that influences registrar’ clinical decisions.
While the supervisor–registrar alliance is foundational to training GPs, research on the educational aspects of learning at work confirmed the importance of an expert ‘community of practice’. Registrars, who learn in practices with non-hierarchical relationships between doctors and staff, which allows knowledge and experiences to be shared effectively, emerge better prepared for the realities of practice.
Registrars learn from seeing experienced General Practitioners at work. This period of supervision is the last, most intensive, and most appropriate place to learn the ethics and attitudes of their chosen vocation.
How experienced GPs write notes, interact with staff, discuss patients, and behave day to day all provide learning opportunities. Registrars are learning via observation, and are likely to perpetuate the observed behavior through their careers.
Observing different consulting styles is standard practice in other countries and could be used more in Australia. In particular, international medical graduates new to Australian general practice environments will gain from observing experienced GPs’ scope of practice and skills.
Coaching is a specific process of direct instruction. Experienced GPs may need to consciously deconstruct and clearly articulate skills that have become automatic. Supervisors assist registrars in reflecting on their learning by discussing cases in structured teaching sessions and via ad hoc teaching between or during consultations.
A thorough orientation is a sound investment of time that kick-starts the educational alliance process. Providing registrars with additional time to learn the practice’s computer and local referral systems, practice protocols, and become familiar with local team members increases their confidence and boosts their productivity later on.
Orientation also allows the local GPs and their team to become familiar with the registrars, their backgrounds, experience, and learning requirements. This creates a tailored learning environment for registrars, who in turn contribute their skills to the practice.
Protecting registrars from the pressure of initially seeing too many patients is important for their confidence and education. Even relatively senior registrars need time to adapt to a new practice, especially if switching from or to an Aboriginal and Torres Strait Islander health service. Later on, increasing consultation rates provides valuable preparation for vocational examinations and clinical work post-qualification.
Registrars consistently report the importance of having accessible, approachable, and expert GPs as their supervisors. Registrars have to be confident their supervisors will welcome and respond to their questions. They frequently look for reassurance as they adapt to the isolation of general practice. Registrars also appreciate a safe, blame-free environment.
Registrars in training practices work behind closed doors and with more autonomy than allowed during their hospital training. Critically, training practices oversee patient safety while registrars are learning. All practice staff has a role in ensuring patient safety by observing the registrar and reporting patient feedback and any concerns or observations they may have. Supervisors should supplement reactive supervision with proactive supervision by undertaking direct observation of consultations, random case analysis, or other monitoring activities.
Silence is not golden for general practice supervisors. If registrars are not asking questions, it generally means either they are aware of what they do not know but are too afraid to ask, or they do not know what they do not know. Both situations are potentially hazardous and need addressing non-confrontationally.
Registrars should be exposed to all aspects of their future work environment. The experience of seeing patients in nursing homes, in hospitals or at home is important. They also benefit from participating in practice meetings, and in being exposed to staff discussions and financial management issues. Continuity of care is educational as it teaches registrars the impact of their management and how problems change over time.
Monitor and assess the registrar’s progress is primarily the supervisor’s responsibility, but their progress is richer if the whole practice is involved. Providing feedback is an essential part of the learning process, and registrars appreciate supervisors ‘who dare to give constructive criticism’.
Increasing numbers of GPs are working part-time, so a team may provide supervision of a registrar. One individual should to take responsibility as the primary supervisor and coordinate regular communication with the supervising team. This may be facilitated by email rather than face-to-face. The discussion should focus on a registrar’s strengths and on identifying areas for development.
Registrars are often the most senior learners within teaching practices. While providing registrars with the opportunity to teach junior doctors or medical students helps their learning, it is important not to expect too much from them too soon.
In hospitals, registrars teach juniors, however, the consultant retains clinical responsibility for patients. In general, supervisors rarely review practice patients seen by registrars, which is unusual in a training context. Registrars can teach students in tutorials or have students observe consultations; however, registrars are not qualified as independent practitioners and are not authorized to take clinical responsibility for students who see patients.
General practice in rural areas usually includes on-call responsibility for hospital duties and emergency care. The degree of procedural work delivered by general practice registrars should be determined by a hospital privileging committee. Issues of supervision can be difficult if a registrar is fully qualified in a procedural skill but needs more supervision for office-based practice. Expectations regarding supervision when registrars are on call often require careful management as there is a disconnect between employing registrars as part of the workforce while giving registrars learning opportunities. Registrars in remote practice face psychosocial and cultural challenges. They have to adapt to living and working in isolated environments, where they may not understand or share their patients’ cultural perspectives on health. Support from cultural mentors is essential for registrars working in
remote Aboriginal and Torres Strait Islander communities and are strongly recommended for all registrars entering those environments to promote a culturally competent practice.
The apprenticeship-style learning model for prospective GPs is fundamental to creating the next generation of GPs. It is important that one supervisor takes responsibility for planning and supporting learning within the practice environment, and for that experienced GP to provide both proactive and reactive supervision. Current evidence and educational theory emphasize learning in a community of practice, where all staff in a teaching practice positively influences registrars towards good practice.