General practice trainee help-seeking, and supervisor input, during trainee consultations with patients

Abstract

This predominantly qualitative research explored general practice trainee help-seeking from clinical supervisors during trainee consultations with patients. Obtaining supervisor input into patient care is widely believed to be important for ensuring patient safety and promoting trainee learning and professional development. Help-seeking and supervisory assistance during general practice trainee consultations afford particular opportunities for trainee learning, clinical oversight and timely intervention in patient management. However empirical studies of help-seeking in general practice training are limited, and the area remains under-theorised.The following research questions were addressed:1. When and how do general practitioner trainees seek help from their supervisors during consultations to provide input to patient care?2. What role does trainee help-seeking and supervisor input during consultations play in general practice training?The author took a pragmatic, agnostic approach to the ultimate questions of ontology and epistemology (the nature of Reality, Truth and Meaning). The methodological approach of the thesis was the compromise position of constructivist realism, which acknowledges that although research participant accounts are socially constructed with particular audiences and self-presentation agendas in mind, and interpreted in the light of researcher assumptions and positions, analysis of these accounts may nevertheless cast useful light on the personal, social and physical worlds with which they are linked. The author adopted a social cognitivist approach to work-based learning, and used the psychological theory of planned behaviour to structure her analysis.Initial focus group discussions and paired interviews were undertaken with trainees and supervisors, followed by an observational study with different participants. The latter included direct observation of 131 trainee consultations followed by individual interviews with the 23 trainee participants immediately after each observational session. An inductive thematic analysis of the qualitative data was undertaken, complemented by a case study approach. A survey study, which included a patient encounter tracking tool completed by trainees, was nested within the research. The analysis of survey responses used descriptive statistics and logistic multivariable regression analyses.Key findings include the following:1. In the initial weeks of their transition from hospital practice new trainees seek frequent operational and clinical assistance to avoid consultation breakdown. Following this transition, the frequency of in-consultation supervisory assistance falls rapidly, as trainees learn to adopt coping routines, including a step-wise approach to consultations, which enable them to practise with a relatively high level of clinical autonomy, and defer much supervisory assistance until more convenient times.2. Supervisor input during consultations has a key role in reassuring patients, backing up the trainee, and reassuring the trainee that they have not “missed anything serious”. Trainee help-seeking also has a performative function in demonstrating the trainee’s commitment to safe patient care. Both trainees and supervisors emphasise its critical role in ensuring patient safety.3. Trainees experience a number of challenges in seeking in-consultation supervisory assistance in general practice training. The barriers to help-seeking may be greater than in hospital settings, where expectations are often clearer to trainees, and assistance more accessible and less disruptive of the requirements of work. Trainees are purposeful in whom they approach for in-consultation assistance, and may appraise supervisor advice critically.4. Supervisor entrustment, trainee self-entrustment and patient trust in the trainee and training practice, are interwoven in general practice training. Supervisor and trainee scripts and etiquette for in-consultation supervisory assistance, including the use of ‘second opinion’ talk and soft correction strategies, are strategic in attempting to promote all three entrustment processes. These scripts, and other constraints on the provision of in-consultation supervisory assistance may, however, reduce the utility of this assistance, and its role in trainee guidance and learning. Patient review and follow-up are important mechanisms for both patient safety and trainee learning in general practice training.5. New information about the configurations and modalities used to obtain in-consultation supervisory assistance is presented, including the important finding that 12.4% of trainees rarely or never obtained this assistance in person together with both supervisor and patient, suggesting additional barriers in some training practices and/or trainees. Trainees rated their perceptions of several barriers to in-consultation supervisory assistance, including losing face in front of patients. Surprisingly, no associations were found between trainee perceptions of these barriers and the frequency of obtaining in-consultation supervisory assistance.6. Trainees have limited exposure to expert practice, and may feel isolated and vulnerable. Findings highlight the importance of more expansive and candid post-consultation clinical discussions which complement timely, focused in-consultation supervisory assistance, and of the educational and pastoral opportunities afforded by teaching visits from external clinicians which include direct observation of entire trainee consulting sessions.A number of research findings have been integrated into training interventions for general practitioner supervisors and trainees which aim to enhance the effectiveness, appropriateness and efficiency of in-consultation supervisory assistance. Important areas for further research include the perspectives of patients in training practices, the supervision of trainees who are performing below expectations, and the development of expertise in general practice.