Finding and addressing weaknesses in GP supervisor professional development.

BACKGROUND: The Royal Australian College of General Practitioners' Standards for general practice training require supervisor continuing professional development (PD) to meet the needs of the individual supervisors and develop the supervisory team. OBJECTIVE: The aim of this article is to explore current supervisor PD and consider how it might better meet the outcomes described in the standards. DISCUSSION: General practitioner supervisor PD delivered by regional training organisations (RTOs) continues to operate without a national curriculum. It is predominantly workshop based and is complemented in some RTOs by online modules. Workshop learning is important for supervisor identity formation and establishing and maintaining communities of practice. Current programs are not structured to deliver individualised supervisor PD or develop the in-practice supervision team. Supervisors may struggle to translate workshop learning into changes in their practice. An in-practice quality improvement intervention facilitated by a visiting medical educator has been developed to address weaknesses in current supervisor PD. This intervention is ready to be trialled and further evaluated.

Should I stay or should I go? Observation post-vaccination during the COVID-19 pandemic and the law of unintended consequences.

BACKGROUND: Standard practice after all vaccinations in Australia is to observe patients for 15min. During the coronavirus disease 2019 (COVID-19) pandemic, could the risk of contracting and dying from COVID-19 acquired in the waiting room be greater than the risk of dying from post-vaccine anaphylaxis when leaving immediately? METHODS: The risks are modelled for a patient aged 70+years attending for annual influenza vaccination in a typical Australian general practice clinic. The risk of death from anaphylaxis is estimated based on known rates of anaphylaxis shortly after influenza vaccination. The risk of acquiring COVID-19 during a 15-min wait and then dying from that infection is estimated using the COVID-19 Aerosol Transmission Estimator and COVID-19 Risk Calculator. RESULTS: Other than at times of extremely low COVID-19 prevalence, the risk of death from anaphylaxis for a patient aged 70+years leaving immediately after influenza vaccine is less than the risk of death from COVID-19 acquired via aerosol transmission during a 15-min wait. The risk of death from COVID-19 is greatest for the unimmunised and when masks are not worn. CONCLUSIONS: A more nuanced approach to advice post-vaccination is recommended that considers current COVID-19 prevalence and virulence, the characteristics of the waiting room, the risk of anaphylaxis, and the patient's susceptibility to death from COVID-19. There are many circumstances where it would be safer for a patient to leave immediately after vaccination.

Using organisational role theory and job analysis to identify and define the roles of an effective Australian general practice supervisor.

General practice (GP) supervisors - the key resource for training the future GP workforce - are often described as 'occupying a role' or enacting a series of roles. However, as much of the discourse uses a lay understanding of role, or merely hints at theory, a significant body of theoretical literature is underutilised. We reasoned that a more rigorous application of role theory might provide a conceptually clearer account of the GP-supervisor's job. To this end, we describe the use of organisational role theory and job analysis to identify and define the roles of the Australian GP-supervisor. Our search of the academic literature identified 64 role titles, which we condensed to an initial iteration of core roles, using inclusion and exclusion criteria. We analysed GP training organisations' documents to map embedded supervisory tasks against our list of roles to verify their presence, review our role titles and definitions, and look for additional roles that we may have missed. We used subject matter experts iteratively, to authenticate a final list of ten roles and their accompanying definitions, which can be used to support Australian GP-supervisors to perform effectively. We encourage those who support GP-supervisors in other countries and those who educate other health professionals in primary care settings to review the roles to judge whether they are transferable to their contexts.

Random case analysis in general practice clinical team meetings.

BACKGROUND: The Medical Board of Australia intends to mandate that at least 25% of continuing professional development (CPD) is focused on performance review. OBJECTIVE: The aim of this article is to describe how random case analysis (RCA) can be used for performance review in general practice clinical team meetings, and outline its benefits and challenges. DISCUSSION: RCA is a powerful learning method for CPD. Involving peers in case review allows practice quality improvement and safety issues to be explored. Planning is required to overcome logistic and legal barriers and to ensure accreditation of the activity by The Royal Australian College of General Practitioners. Vital to the success of RCA is a supportive educational environment and the provision of learner-centred and specific feedback.

Flags for seeking help: making supervisor expectations of general practice trainee help-seeking explicit.

Timely supervisor input into patient care plays a key role in ensuring the safety of patients under the care of general practice trainees. Current models of clinical supervision for trainees in both hospital and general practice training have, however, been criticised for placing too much onus on the trainee to request assistance, despite the many known barriers for trainees to do so. An important barrier to general practice trainee help-seeking is trainee uncertainty about when and how their clinical supervisor expects them to seek this assistance. We introduce a tool, 'Flags for Seeking Help', which was modified from an existing checklist, to assist supervisors to tailor their input to the care of their trainee's patients. The tool aims to make supervisor expectations of trainees explicit, including when trainees should request assistance during consultations (rather than defer this until more convenient opportunities) and when this assistance should be face-to-face (rather than by phone or messaging systems). Our aim is to reduce the barriers for trainees to request in-consultation and face-to-face supervision, in particular, when it is indicated. We outline the evidence which informed the development of the tool, and present some preliminary findings from a pilot in Australian general practice training.

Getting good help: a guide for reflection, debriefing and feedback conversations about in-consultation supervision.

Timely supervisor input to the care of their trainees' patients plays a key role in ensuring the safety of patients under the care of general practice trainees. Supervisor responses to trainee calls for assistance are also important for trainee learning and professional identity formation. The in-consultation supervisory encounter in general practice training is, however, a complex social space with multiple trainee, supervisor and patient agendas. Trainee requests for assistance during their consultations are known to present general practitioner supervisors with a number of challenges. From the trainee's perspective, a safe learning environment is essential during these supervisory interactions. A number of factors may act as barriers to, or reduce the usefulness of, in-consultation assistance in particular, resulting in trainees being less likely to seek such assistance on future occasions. It is therefore important to improve both trainee and supervisor skills in safe, effective and efficient in-consultation supervision. Making time for trainee and supervisor conversations about their help-seeking and help provision may uncover opportunities for improving skills, aligning agendas and enhancing outcomes. Finding time for debriefing, reflection and effective feedback conversations may be challenging, however, and opportunities for trainees to provide feedback to their supervisors are known to be particularly limited. We introduce a Debriefing, Reflection and Feedback Guide which is designed to prompt reflection, and structure effective and efficient debriefing and reciprocal feedback conversations. We outline the evidence which informed the development of the Guides, and present some preliminary findings from a pilot in Australian general practice training.

Good help: a model for providing in-consultation supervision of general practice trainees.

Timely clinical supervision of trainee consultations plays a key role in ensuring the safety of patients under the care of general practice trainees, and in trainee learning and professional development. Trainee requests for assistance during their consultations present supervisors with a number of challenges, however, and a number of factors act as barriers to, or reduce the utility of, this in-consultation assistance from the trainee's perspective. Face-to-face supervision in the presence of the patient presents particular challenges and opportunities. It is important to address barriers to trainee help-seeking and improve both trainee and supervisor skills in promoting safe, effective and efficient in-consultation supervision. We introduce a model (ß-LACTAM) to assist supervisors in planning and delivering their face-to-face in-consultation supervision. The recent evidence which informed the development of this model is outlined, and some preliminary findings from a pilot of ß-LACTAM in Australian general practice training are presented.

A 'call for help' list for Australian general practice registrars.

BACKGROUND AND OBJECTIVES: Currently when undergoing Australian general practice training, a registrar must determine when clinical supervision is needed. The aim of this study was to identify situations in early Australian general practice training requiring closer supervision and consider how this can be achieved. METHOD: The study used a qualitative approach involving 75 registrars, supervisors and medical educators from seven focus groups in Victoria and Tasmania. RESULTS: Eighty circumstances in which a registrar should call their general practice supervisor were identified. Participants indicated the 'call for help' list should be modified early in the term after considering the registrar's prior experience, and through the term as supervision and teaching identifies readiness for independent practice. DISCUSSION: The size of the list developed by the focus groups reflects the breadth of general practice. It is a 'call for help' list rather than a safety checklist as it is not exclusively concerned with high-risk scenarios and includes broad triggers to call for help. The 'call for help' list is an aid to patient safety and the supervisor-registrar alliance.

Closer supervision in Australian general practice training: planning major system change.

Major system change involving closer supervision of trainee GP registrars in Australia is warranted. Change management guidelines recommend involving stakeholders in developing change. The views of those involved in general practice training about current and potential supervisory practice were explored. Semi-structured interviews were conducted with a lead medical educator from nine Australian regions. Focus groups were conducted with GP supervisors and GP registrars. Transcripts from the interviews and focus groups were analysed using conventional content analysis, with themes emerging inductively from the data. The findings were that over 1-3 months, a registrar could progress from their supervisor observing all consultations through to the registrar only calling when they identify the need for help. There is strong support from registrars for this change to closer supervision, but less support from supervisors and educators. Barriers to the proposed change include high clinical demand competing with teaching capacity, inadequate payment for closer supervision and supervisors lacking skills or motivation to have a more active role in registrar supervision. If funding and logistic barriers to change are addressed, a change to a closer level of supervision is possible. A pilot study to further refine the change is indicated.

Tell me if there is a problem: safety in early general practice training.

In contrast to other comparable countries, trainees commencing general practice in Australia can see patients without being required to contact their supervisor. To understand how patient safety in early training is managed a qualitative study design using semi-structured interviews was used. A lead medical educator from each of the nine Australian Regional Training Organisations (RTOs) was interviewed. Transcriptions of interviews were analysed to identify themes. RTOs do not mandate a period of direct observation of trainees and the use of safety checklists for supervision is variable and not monitored. The oversight of training practices by RTOs mirrors that of trainees by supervisors. The onus falls on those being supervised to identify the need for assistance. Despite this, lead medical educators still consider the commencement of general practice training to be safe. Other factors found potentially to impact on safety include the variability of training practices and supervision; the complex RTO-practice relationship; quota-driven selection of doctors into general practice; and the negative impact on education of the funding model. Patient safety may be improved by a period of direct observation of potential trainees prior to the commencement of general practice training and the use of checklists to encourage supervision of high risk activities.

Adding random case analysis to direct observation (ARCADO) - Updating the external clinical teaching visit to improve general practice registrar assessments.

BACKGROUND: In response to the advent of competency-based training and the increase in the number of general practice registrars, the Australian general practice education community is seeking valid, reliable, time-efficient and cost-efficient tools to assess registrars. Despite the central role of the external clinical teaching visit (ECTV) in formative assessment of general practice registrars, the ECTV has been an infrequent subject of research or evaluation. OBJECTIVE: The objective of this article is to report on the development of a new approach to ECTV that adds random case analysis to direct observation of consultations - ARCADO ECTV. DISCUSSION: ARCADO ECTV is a flexible, acceptable and time-efficient formative assessment. The two assessment approaches in the ARCADO ECTV provide complementary insights into the registrar's performance. At least three observed consultations are required to ensure adequate assessment of communications skills. Medical records need to be of recent consultations. There is scope for development of the ARCADO ECTV as a summative assessment.

A blended supervision model in Australian general practice training.

BACKGROUND: The Royal Australian College of General Practitioners' Standards for general practice training allow different models of registrar supervision, provided these models achieve the outcomes of facilitating registrars' learning and ensuring patient safety. OBJECTIVE: In this article, we describe a model of supervision called 'blended supervision', and its initial implementation and evaluation. DISCUSSION: The blended supervision model integrates offsite supervision with available local supervision resources. It is a pragmatic alternative to traditional supervision. Further evaluation of the cost-effectiveness, safety and effectiveness of this model is required, as is the recruitment and training of remote supervisors. A framework of questions was developed to outline the training practice's supervision methods and explain how blended supervision is achieving supervision and teaching outcomes. The supervision and teaching framework can be used to understand the supervision methods of all practices, not just practices using blended supervision.

ARCADO - Adding random case analysis to direct observation in workplace-based formative assessment of general practice registrars.

BACKGROUND: Workplace-based formative assessments using consultation observation are currently conducted during the Australian general practice training program. Assessment reliability is improved by using multiple assessment methods. The aim of this study was to explore experiences of general practice medical educator assessors and registrars (trainees) when adding random case analysis to direct observation (ARCADO) during formative workplace-based assessments. METHODS: A sample of general practice medical educators and matched registrars were recruited. Following the ARCADO workplace assessment, semi-structured qualitative interviews were conducted. The data was analysed thematically. RESULTS: Ten registrars and eight medical educators participated. Four major themes emerged - formative versus summative assessment; strengths (acceptability, flexibility, time efficiency, complementarity and authenticity); weaknesses (reduced observation and integrity risks); and contextual factors (variation in assessment content, assessment timing, registrar-medical educator relationship, medical educator's approach and registrar ability). CONCLUSION: ARCADO is a well-accepted workplace-based formative assessment perceived by registrars and assessors to be valid and flexible. The use of ARCADO enabled complementary insights that would not have been achieved with direct observation alone. Whilst there are some contextual factors to be considered in its implementation, ARCADO appears to have utility as formative assessment and, subject to further evaluation, high-stakes assessment.

Towards an educational continuing professional development (EdCPD) curriculum for Australian general practice supervisors.

BACKGROUND: Within the apprenticeship model of general practice training, the majority of teaching and learning occurs in the practice under the guidance of the general practice supervisor. One of the foundations of a high-quality general practice training program is the delivery of relevant, evidence-based educational continuing professional development (EdCPD) for general practice supervisors. Despite The Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) standards requiring EdCPD, there is currently no standardised educational curriculum for Australian general practice supervisors. There are a number of emerging themes with significant implications for future general practice supervisor EdCPD. These include clinical supervision and structural issues, capacity constraints, and emerging educational issues. OBJECTIVE: We propose the development of a core curriculum for general practice supervisors that is competency-based and evidence-based, and reflects the changing landscape of Australian general practice training. DISCUSSION: A national general practice supervisor core curriculum would provide standardisation, encourage collaboration, allow for regional adaptation, focus on developing competencies and require rigorous evaluation.

Why and how do general practitioners teach? An exploration of the motivations and experiences of rural Australian general practitioner supervisors.

BACKGROUND: In medical education, a learner-centred approach is recommended. There is also a trend towards workplace-based learning outside of the hospital setting. In Australia, this has resulted in an increased need for General Practitioner (GP) supervisors who are receptive to using adult learning principles in their teaching. Little is known about what motivates Australian GP supervisors and how they currently teach. METHODS: A qualitative study involving semi-structured interviews with 20 rural GP supervisors who work within one Regional Training Provider region in Australia explored their reasons for being a supervisor and how they performed their role. Data was analysed using a thematic analysis approach. RESULTS: GP supervisors identified both personal and professional benefits in being a supervisor, as well as some benefits for their practice. Supervision fulfilled a perceived broader responsibility to the profession and community, though they felt it had little impact on rural retention of doctors. While financial issues did not provide significant motivation to teach, the increasing financial inequity compared with providing direct patient care might impact negatively on the decision to be or to remain a supervisor in the future. The principal challenge for supervisors was finding time for teaching. Despite this, there was little evidence of supervisors adopting strategies to reduce teaching load. Teaching methods were reported in the majority to be case-based with styles extending from didactic to coach/facilitator. The two-way collegiate relationship with a registrar was valued, with supervisors taking an interest in the registrars beyond their development as a clinician. CONCLUSION: Supervisors report positively on their teaching and mentoring roles. Recruitment strategies that highlight the personal and professional benefits that supervision offers are needed. Practices need assistance to adopt models of supervision and teaching that will help supervisors productively manage the increasing number of learners in their practices. Educational institutions should facilitate the development and maintenance of supportive supervision and a learning culture within teaching practices. Given the variety of teaching approaches, evaluation of in-practice teaching is recommended.

Are GP supervisors confident they can assess registrar competence and safety, and what methods do they use?

BACKGROUND: The new Royal Australian College of General Practitioners' vocational training standards emphasise patient safety and matching the level of supervision to registrar competence. METHODS: All supervisors attending a regional training provider's annual education workshop were surveyed about their overall confidence in assessing the safety of their registrars' patients, their registrars' competence across the five RACGP domains of general practice and supervision methods used. RESULTS: Of 84 supervisors, 92.8% expressed overall confidence in their ability to assess their registrars' competence and 10.7% were totally confident. Consultation observation and audit techniques were infrequently used in their assessments. DISCUSSION: Supervisors reported confidence in their ability to assess their registrars' competence, suggesting readiness for outcomes-based standards. The low frequency of using supervision methods considered more effective in targeting registrars' 'unknown unknowns' and the reduction in confidence with greater experiences as a supervisor raises concerns about the accuracy of this self-assessment.

GP supervisors--an investigation into their motivations and teaching activities.

BACKGROUND: There is little empirical information on how general practitioner (GP) supervisors teach and the reasons for the variation in their teaching methods. Could the variation be due to differing motivations to teach? METHODS: Supervisors from one regional training provider who attended educational workshops in 2013 were surveyed, seeking infor-mation on their motivation to become and remain a supervisor, and the frequency of use of selected teaching activities. RESULTS: The majority of respondents cited intrinsic motivators, including enjoying teaching (84%), contribution to the profession and community (82%), adding variety (78%) and workforce/succession planning (69%), as reasons for becoming GP supervisors. The expected relationships between motivations and teaching activities were not found. DISCUSSION: Variation in teaching activities used by supervisors does not appear to be associated with differing motivations. Measuring the use of teaching activities is not a mechanism to determine a supervisor's commitment to teaching.

Random case analysis - a new framework for Australian general practice training.

BACKGROUND: Random case analysis is a powerful tool for clinical supervision, teaching and assessment. It can identify gaps in knowledge, assess clinical reasoning skills and allow provision of critical and timely feedback. OBJECTIVE: In this article, we propose a new framework for random case analysis based on The Royal Australian College of General Practitioners curriculum. The framework also includes an approach to deeper exploration of clinical reasoning by the use of a quadrant of contextual factors - the doctor, the patient, the problem and the system. DISCUSSION: Using the new framework, the breadth of learning opportunities in the consultation can be explored. These include communication skills and patient centred practice; applied clinical knowledge and tolerance of uncertainty; population health and preventive care; professional and ethical practice; and legal and organisational skills. We believe that this new framework will facilitate greater use of this powerful teaching method in Australian general practice training.

Avoiding 'consultation interruptus' - a model for the daily supervision and teaching of general practice registrars.

BACKGROUND: In general practice placements, much of the teaching occurs when the supervisor is called into the consulting room by the registrar while the patient is still present. How should this unique learning environment affect on teaching strategies? OBJECTIVE: This article analyses the nature of general practice teaching and proposes a different model of teaching in a 'patient-present' environment. DISCUSSION: General practice registrars are advanced learners who benefit from exploration of clinical reasoning in patient encounters. However, teaching interactions that undermine the patient-registrar relationship will affect the registrar's exposure to continuity of care. In this article, a model for the supervisor to follow when entering the registrar's consulting room while the patient is still present is described. This model emphasises leaving the registrar in control of the consultation and the use of 'thinking aloud' to explore clinical reasoning while at the same time preserving the relationship between registrar and patient.