The identification of the general practice registrar needing assistance

Abstract

Background

Doctors undertaking vocational training in general practice in Australia may require assistance, in addition to the normal training offered as part of their training programme. Issues requiring assistance may go undetected for a period of time. Delay in the identification of issues leads to delay in the provision of the assistance. The aim of this study is to determine the most common reasons registrars require extra assistance, and how these issues are identified. The findings of this study will provide direction for 21 regionally based training providers (RTPs) to develop improved tools to ensure earlier detection of registrars requiring assistance.

Method

This study is based on qualitative research methods, using semi-structured interviews with senior medical education staff of four regional general practice training providers in Victoria, Australia.

Results

Issues identified included language and cultural issues, applied knowledge and skills, attitude and professionalism, and health and family issues.

The principal method that training providers identified issues was via the GP supervisor. This was predominantly by informal communication, rather than formal evaluation sheets. Other methods included the external clinical teaching visit and other training formative assessments. These more formalised procedures were more likely to identify issues later than desired. They were also used as a way of clarifying suspected problems. The selection process was not felt to be helpful, and the examinations provided information too late.

Conclusion

An increased awareness of the potential issues leading to a registrar to require assistance enables identification and subsequent action to occur in a more timely and more useful fashion. Informal communication between practices and training programme staff should be encouraged to enable these issues to be dealt with early in training.

What this study adds:

1. Recognition of factors leading to remediation in general practice registrars in Australia.

2. Identification of registrars requiring assistance.

3. Development of a tool to assist training providers to identify issues early.

Background

Post-graduate vocational training for general practice in Australia occurs within the federally funded Australian General Practice Training Programme (AGPT) under the policies of General Practice Education and Training (GPET). At the time of this study, training is contracted out to 21 RTPs. On completing training and assessment, registrars are awarded Fellowship of either the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine.

From personal experience and communications with providers, registrars do not always progress smoothly through training. There are many issues that may interfere with training, and require extra support or training from the RTP.

The aim of this study is to determine the most common reasons registrars require extra assistance, and how these issues are identified. The findings of this study will provide direction for RTPs to develop improved tools to ensure earlier detection of registrars requiring assistance.

Method

Four interviews were held with senior medical educators of Victorian RTPs in May 2009. Three of the RTPs are based in rural and regional areas, while one is metropolitan-based. Semi-structured, in-depth interviews were conducted, lasting an average of one hour, using open questions and reflective statements. Interviewees were asked to consider registrars who had been identified as needing assistance beyond that normally provided as part of their training program. Interviewees were asked to elaborate on the cases discussed, in an effort to clarify the issues identified. They were asked to describe how these issues were identified, and the process used to define and manage their concerns. Interviews were recorded on both digital and tape recorders.

The major ethical concern of this project was the privacy of the registrars being discussed. This issue was addressed by asking participants to not use the names of registrars, practices or towns.

Interviews were then transcribed verbatim. Key themes were identified using NVivo8 software. Categories were developed inductively by reviewing the transcripts and replaying recordings of the interviews. The transcripts were indexed using these themes. Issues requiring assistance and the way they were detected were identified and classified separately.

Ethics approval was provided by the UNSW Human Research Ethics Committee.

Results

Issues identified as requiring assistance included language and cultural issues, knowledge and skills, attitudinal and professional issues, and health and family issues. As well as these registrar-related issues, situational issues were also raised.

Methods of identifying the registrar needing assistance included practice-identified, registrar self-identified and RTP-identified formative assessment.

Issues requiring assistance

Language and cultural issues

The most commonly raised issue requiring assistance was English language skills in registrars with English as a second language. Concerns with language skills appeared to be a greater issue in the rurally-based RTPs. Expressive English language skills seemed to be more of a problem than receptive skills. However, registrars were reported as sometimes missing subtle uses of language and local slang.

Expressive language issues are also important in the educational setting, and affect the participation of a registrar in workshops.

Language issues were commonly associated with other issues requiring assistance.

Cultural issues were often linked with language, but interviewees were able to separate the issues. Cultural issues often related to the doctor-patient relationship and expectations of the consultation.

“In Australia patients expect to be given a fair degree of autonomy in their medical care, and people from other cultures don’t necessarily have that background.”

Knowledge and skills

The commonest concern in this category was applied knowledge. Having worked in the hospital setting, some GP registrars feel confident in performing various procedures, but are unable to recognise the effect of the different setting on the potential outcomes of the procedure.

“She doesn’t want to ring up the phone and say I’m just about to put a chest tube in, she just does it anyway.”

Lack of knowledge is often not seen as a problem initially. Interviewees reported that registrars are actively encouraged to identify their own knowledge gaps, and add items regularly to their learning plans.

Consulting skills were presented as an issue, often linked with language and cultural issues, but sometimes as a stand-alone issue.

“He had done a lot of emergency work and was doing lots of weekends in ... Emergency (Department) and saw the problem, dealt with the problem and you were out the door.”

Sometimes registrars have difficulty accepting the uncertain nature of general practice. Some registrars felt they needed exact answers to each problem. This often presented to the practice as a time management problem.

“she really thought she had to do everything then and there.”

Attitude and professional issues

Unprofessional behaviour and inappropriate interpersonal relationships form a frustrating and difficult group of issues raised in the interviews. Employment-related issues with contracts, payments and conditions of employment were cited. Examples were given of registrars being rude to, swearing at, and generally mistreating practice staff.

“she would ring up that morning and say she wasn’t coming to work.”

“angry outbursts, floods of angry words, inappropriate language in front of staff”

Concerns were also raised about training-related issues, and compliance with compulsory training requirements.

Health, personal and family issues

Illness, particularly mental illness, features infrequently in the interviews as an issue affecting a GP registrar’s training. Mental health issues were the only issues that were reported as self-identified by the registrar.

Existing mental health issues had also been exacerbated by the training programme requirements, and practice pressures.

Other registrars had personal, social and family issues affecting their performance and training potential. In a number of situations, registrars were living away from their families and travelling on weekends to see them.

Situational issues

In some situations, the combination of that particular registrar and that particular practice at that particular time causes problems to arise. A few examples were given of practices complaining about an individual registrar’s competence. In previous or later terms, however, there were no similar complaints. Practices may have different expectations of the ability of registrars, and supervisors may have their own pressures of running the business side of the practice.

Practice managers were cited as contributing to some of the issues. Examples given include mistakes made in pay, or attitude towards training or a particular registrar.

Identification

Practice-identified

The majority of issues raised were communicated to the training provider by the training supervisor. Supervisors seem to get their information from a range of sources, including direct observation, staff concerns and patient complaints. In most cases discussed, the supervisor provided the initial concerns.

“There were serious concerns raised by the supervisor.”

“more patients coming out disgruntled.”

Some registrar issues were communicated directly by practice managers to RTP staff.

Concerned supervisors and practice managers were more likely to report issues via informal telephone calls, rather than in the written reports, which are a requirement of training programmes. There was also a tendency for written reports to not necessarily contain the best information.

“More often than not, the information isn’t there, or it’s not adequately defined in the supervisor’s report, when I’ve looked back.”

“I think the key lies in your relationship between the RTP and the supervisor more than anything.”

Interviewees were all keen to have issues or concerns identified as early as possible, in order that further evaluation and assistance could be arranged in a timely manner.

In some instances, there is a delay in issues being identified or communicated to the RTP. Registrars who are considered to be “nice” by supervisor, practice staff and patients may often be delayed in their identification.

In some examples provided, practices have contributed to a delay in identification of the issues. They have believed that they should be able to handle the situation themselves, or fear that the registrar’s lack of skills may reflect badly on their skills as a teaching practice. Supervisors who do not play an active role in teaching, particularly with direct observation of consultations, may miss the cues that there is an issue.

External clinical teaching visits (ECTVs) and other formative assessment

RTPs use a range of formative assessment methods. External clinical teaching visits are a compulsory requirement of training. An experienced GP from another practice sits in with the registrar during a half-day of consultations, providing verbal feedback and a written report. Interviewees all found these visits useful in providing information regarding a registrar’s progress. Mostly they were used to obtain further information about concerns raised by other means.

“The teaching visit indicated that he had some major issues in the way that he ran the consultation and some knowledge issues.”

It was acknowledged that the ECTV does not always pick up or confirm issues. Time management issues are often masked during an ECTV, where the registrar is generally booked more lightly than usual. Behavioural and attitudinal issues can also easily be covered up when the consultation is being observed.

“It won’t get picked up in an ECTV where you’ve often booked less patients anyway. And it depends on whatever comes through the door. So a review for something might not be so difficult. Or there might not be as challenging cases.”

ECTVs are commonly used as the first tool after an issue has been raised. An experienced visitor will use the ECTV to confirm issues raised, and gather extra information.

The value of ECTV reports are variable according to the visitor’s experience and willingness to identify and voice their concerns.

RTPs use a variety of tools in an early needs assessment. This assessment may be fairly informal, in the form of an interview at an early workshop. Generally, it is used to establish the registrar’s learning needs. Early needs assessment tools were generally found to be not very helpful in identifying the registrar needing assistance.

“...principally used as feedback for the registrars and the supervisors to look at for kicking off the teaching and seeing what needs might be addressed early in their teaching.”

Issues raised at early assessments tend to prompt further review, mostly with an early ECT visit as mentioned above.

Training advisor meetings involve an individual contact between a registrar and a medical educator. The main purpose of the meeting is to assess how the registrar feels they are going, and whether they have the necessary resources to address their learning needs. These meetings were rarely a source of initial information about a registrar needing assistance, but were often used once an issue had been suspected.

Attendance and participation in education workshops were frequently mentioned as a source of information about registrars needing assistance. These may provide the medical educators with information about how a registrar interacts with peers, with some direct observation of the registrar’s behaviour.

“I certainly saw her as being one of those quiet, peripheral registrars who doesn’t say anything.”

“She was flagged because she looked as though she wasn’t participating, and when pressed, really couldn’t participate at the same standard as the rest of them.”

“Very unhappy and very withdrawn and at workshops we realised he wasn’t engaging and you could see that something wasn’t quite right”

Some training providers have a specific part of the workshops set aside for registrars to debrief and discuss any concerns, highlights or problems they experience in their practices.

“The other place you find out lots of information is in the debrief. The debrief session is where you see things aren’t right.”

Attendance and punctuality in attending workshops can also provide an indication of attitude or other problems.

“He didn’t turn up on the second day of the workshop and didn’t let us know after we had a big long discussion about timeliness and participation.”

Some regions have a regular complete registrar review with medical education staff. This review looks at all available information about a registrar’s progress, including written reports and participation in workshops. This process has been useful to identify any early concerns and plan for closer monitoring of a registrar’s performance. However, examples were given of registrars who slipped through even this more rigorous system.

Selection process

Discussions included the use of the AGPT application and selection process as a source of useful information regarding registrar assistance issues. This process is designed and coordinated nationally and conducted locally by each regional training provider. Interviewees described the process as useful for deciding who not to accept into the programme, but not particularly useful for identifying registrars needing assistance.

Registrar self-identified

A couple of examples were provided of registrars who were able to self-identify their additional needs. These were linked to health and personal issues. Insight into a registrar’s additional needs may facilitate the process of assistance. The situation is made more difficult in many of the situations where the registrar has no insight into their issues.

The exam

Despite developing a range of strategies to promote early identification of registrars needing assistance, most interviewees were able to provide examples of registrars failing the exam. Until 2008, all GP registrars were required to complete the RACGP assessment as part of the training requirements. The assessment comprises two written examination papers and a clinical OSCE format examination. In some cases, particularly with failure at multiple attempts, the registrar’s lack of insight inhibits further assistance.

Other situations were described where issues had been suspected, but concerns were not followed through.

“When registrar X fails the exam, suddenly the supervisor says, well that’s no surprise, or the person who’s done the ECTV says, well I expected that.”

Factors affecting the timing of identification and notification

All interviewees agreed that early timing of identification of issues was ideal, so that timely clarification could be arranged and assistance could be provided.

“It’s bad training I think for the fact that someone’s going to need remediation work to only be picked up at the end. It needs to be picked up at the beginning.”

Issues leading to lateness of identification were not always clear. As previously suggested, sometimes it was related to lack of the supervisor identifying issues by direct observation. In other situations, the practice recognised the issue but either decided to try to handle it themselves, or decided not to handle it. In other situations, the issues were identified by both the practice and the RTP, but the registrar’s lack of insight or resistance to change prevented any successful remediation from occurring.

Discussion

Issues identified

In this study,one of the major issues requiring the provision of assistance to registrars was English language skills, particularly in the rural RTPs. Many overseas-trained doctors are required to work in rural areas under federal Australian workforce legislation. This issue amongst international medical graduates (IMGs) has been well documented in the literature in recent years in Australia and other English-speaking countries.^1,2,3,4

Given that many IMGs also have cultural and family issues as well as their language needs, they are given an additional burden of learning, with potentially less available time and study skills.

Applied knowledge and consulting skills were also a common problem, as stated in much of the literature.^5,6,7,8, Medical knowledge can often be gained from books and lectures, but concerns were raised when registrars either under-used or over-used their knowledge and skills. Working in general practice is about knowing one’s own limits of skill and expertise.

Other issues raised were less common, but by no means, less difficult to manage. Due to the small numbers of registrars involved, there was no consensus on the identification of health issues. Like our patients, each health issue needs to be addressed individually.

Method of identification

This study suggests that the most common way for registrars needing assistance to be identified is via feedback from the supervisor and teaching practice. The most useful and timely feedback occurred in an informal manner, mostly by telephone or direct contact. Similar findings have been suggested in other training programmes.⁹Formative assessment tools were generally seen as providing information too late. An increasing recognition of the role of the practice manager in the registrar’s training has encouraged stronger links between RTPs and practice managers. Easy access to medical education and support staff is important for the easy transfer of information.

Interviewees all highlighted the importance of the relationship between the practice (both supervisor and practice manager) and the training provider.

Written or computer-based reports are currently a requirement of training, but were found to be of little value as a source of feedback for training purposes. This concern has been previously raised.⁷Flexibility in the reporting requirements could encourage more useful information being provided using different media.

Timing of identification

It was generally stated that the earlier the issue is identified and clarified, the earlier a process of assistance can be provided. Although early registrar needs assessments are recommended by GPET, there is no universal ideal process for this to occur, and each RTP is developing its own methods. Current methods used were reported as variable in their usefulness. They tended to be more useful for assisting the registrar and supervisor in the development of the registrar’s learning plan, rather than identifying issues needing assistance. Some training providers are conducting specific English language assessments early in training, and arranging specific language tuition for those found needing assistance. Sharing of information between RTPs about methods of early needs assessments could assist in finding more optimal processes.

Variability amongst the supervisor group was identified, with some supervisors being happy with a registrar’s performance, while the next supervisor has concerns. Many reasons for supervisors not voicing their concerns early have already been researched.5,10 As the most useful information was found to come from supervisors in an informal context, mostly by telephone, this study suggests that facilitation of early contact between RTP offices and supervisor could address some of the barriers to reporting.

Limitations of this study

This study only looked at Victorian RTPs. Further interviews with medical educators in other training programmes across Australia would provide greater information, but similar themes would be expected. The issues around language and culture would be well-known to other rural teaching practices, particularly those within relatively close proximity to larger metropolitan areas. Certainly the issues of applied knowledge and skills, attitudes and professionalism and health issues are well documented in the literature, and would be expected in any training programme.^7,8 The method of identification would also be expected to be similar in other states, as written feedback is generally not seen as providing the best information.⁷

Information about registrars in this study was provided by medical educators in RTPs.Further insight into the issues and the identification of issues may be obtained from interviews with GP supervisors. It would be valuable to learn of the cues supervisors pick up on when identifying the registrar needing assistance. A different aspect may be to interview registrars who have been identified as needing assistance, and determining their needs directly.

Conclusion

All medical vocational training programmes have registrars with issues requiring assistance for them to successfully complete their training. Many of these issues seem almost universal, with competency issues, health issues and professionalism issues being widely reported. Language and cultural issues are less commonly researched areas in which registrars may struggle, but were found to be a common issue in this study. Individual training programmes have gradually developed their own systems of assessment and assistance with these issues. Early needs assessment, particularly in English language skills, and appropriate assistance seems to be an important tool for regional training providers to consider.

Very few previous studies had looked at the way these issues were identified in the AGPT. This study suggests methods for monitoring registrar performance, in order to detect problems as early as possible. The identification of GP registrars requiring assistance appears to occur mainly via the supervisor. This mostly occurred by informal methods rather than the required feedback forms. Further encouragement of supervisors to communicate any concerns to RTPs as early as possible should continue. There may be a place for RTPs to make direct contact with supervisors asking them to voice any concerns. Once the initial concerns are raised, all RTPs interviewed have a process of further information gathering before setting down the path of remediation. However, as universally agreed, the earlier that initial concern can be raised, the more time there is for problem clarification and assistance to be provided.

Recommendations

The stated aim of this study is to provide some guidance for RTPs in the early identification of their registrars needing assistance. Recommendations arising from this study are:

• Review of the national selection process - Interviewees agreed that the current process is of little use in identifying successful applicants who will require assistance during their training. Suggested changes to include some evaluation of clinical and language skills as part of the selection process would make this a more useful procedure.

• Early registrar needs assessment - Although this is recommended by GPET, individual RTPs are currently considering their own assessment processes. A system whereby RTPs could pool their resources, or access some further guidance and direction from GPET, could lead to the development of a needs assessment tool that meets the needs of each RTP and assists in the identification of the registrar needing assistance.

• Early RTP contact with supervisors and practice managers - Each interviewee highlighted the importance of informal contact with supervisors and practice managers. Rather than waiting for supervisors to contact the RTP office, which does not always occur, early contact made by the RTP office could flag any potential issues at a more timely stage. RTPs have found that enhancing the relationship between training practices and RTP office has been valuable, and this should continue.

• Further studies in this field should include evaluating the methods that supervisors use to assess their registrar’s progress and performance and to identify their reasons for reporting concerns or not. Interviewees commented on the change in the numbers and demographic details of new applicants, with the increasing popularity of general practice training and the increasing numbers of local medical graduates. This will therefore affect the issues requiring assistance in future years. A repeat of this study in the future will make an interesting comparison, and assist RTPs in keeping abreast of current issues.