General Practice Supervisors Research Articles

Family medicine and general practitioner supervisor wellbeing: a literature review.

Research examining general practice supervisor wellbeing has often been conducted within the context of trainee wellbeing and educational outcomes. To consolidate the current literature regarding the wellbeing of GP supervisors through a 'supervisor-wellbeing' lens. Literature review of original research studies on Embase, Ovid MEDLINE, and Ovid PsycINFO from inception to December 2022. The Embase, Ovid MEDLINE, and Ovid PsycINFO databases were systematically searched from inception to December 2022. Original research studies were eligible if they explored any aspect of wellbeing or burnout (that is, construct conceptualisations, risk and protective factors, implications, or interventions) among GPs involved in educating GP trainees. Reporting quality of included studies was assessed using the QualSyst tool. Results from included studies were narratively synthesised. Data from 26 independent samples were reviewed. Burnout was generally conceptualised using the Leiter and Maslach model. Wellbeing was poorly defined in the literature, largely being conceptualised in personal psychological terms and, to a lesser extent, professional satisfaction. Risk and protective factors were identified and grouped as individual (for example, satisfaction with capacity to teach) and external (for example, autonomy, collegial relationships, resource availability) factors. GP supervisors' wellbeing appeared to affect their job performance and retention. This review identified only two studies evaluating interventions to support GP supervisors' wellbeing. The present review highlights a lack of conceptual clarity and research examining interventions for GP supervisor wellbeing. It provides guidance for future research designed to maximise the wellbeing of GP supervisors and support the wellbeing of trainees.

Becoming a general practice supervisor: A longitudinal multi-case study exploring key supportive factors.

Supervision of trainees in the health care professions is recognised internationally as core to safe and effective patient care. A supervisor workforce in general practice (GP) is critical to the profession and to the communities where they work and can be demanding as general practitioners incorporate workplace-based education and support of their trainees into their daily consulting work. Little is known about how this is experienced by new supervisors; therefore, this research sought to understand factors that play a significant role in the first semester of becoming a supervisor. An exploratory multi-case study design was used; new general practice supervisors were the unit of analysis. Four data sources were captured longitudinally: semi-structured interviews at the beginning and end of the semester, audio diaries throughout and a mid-semester focus group. Template analysis was used, sensitised by a community of practice theoretical framework. Seven new supervisors participated. Five interdependent key factors played a significant role in general practitioners becoming supervisors: (1) making meaning of the role, (2) reconciling multiple roles, (3) building a relationship with the trainee, (4) receiving support from the training practice and the training programme and (5) joining peer communities of new and experienced supervisors. Becoming a general practice supervisor is situated in the context of a workplace delivering clinical services, a training programme and personal life circumstances. It can be challenging and rewarding. Insufficient support may result in unintended attrition. Learning in this role is facilitated by enabling the new supervisor to find meaning in the role; structured allocation of time to engage effectively; a positive trainee-supervisor relationship; administrative support by practices; information, advice and remuneration from the training programme; and interactions with new and experienced supervisor peers.

“What kind of doctor do you want to become?”: Clinical supervisors’ perceptions of their roles in the professional identity formation of General Practice residents

Purpose Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors’ perceptions of their roles in residents’ PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. Materials and methods Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. Results Three themes related to how GP supervisors described their roles in supporting residents’ PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. Conclusions To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor’s perspective and highlight the pivotal roles of the supervisor in a resident’s PIF.

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

ABSTRACT 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.

Mandatory bulk billing policies may have differential rural effects: an exploration of Australian data.

Over the course of the COVID-19 pandemic, Australian general practices have rapidly pivoted to telephone and video call consultations for infection control and prevention. Initially these telehealth consultations were required to be bulk billed (doctors could only charge fees equivalent to the national Medicare Benefits Schedule (MBS)). The potential impact of this policy on general practices &minus; and particularly rural general practices - has been difficult to assess because there is limited published data about which practices are less likely to bulk bill and therefore more impacted by mandatory bulk billing policies. There was concern that bulk billing only policies could have a broader impact on rural practices, which may rely on mixed or private billing for viability in small communities where complex care is often needed. This study aimed to understand the patterns of bulk billing nationally and explore the characteristics of practices more or less likely to bulk bill patients, to identify the potential impact of a rapid shift to bulk billing only policies. General practice bulk billing patterns were described using aggregate statistics from Australian Department of Health public MBS datasets. Bulk billing rates were explored over time by rurality, and state or territory. Next, questions about bulk billing were included in a cross-sectional survey of practices conducted in 2019 by General Practice Supervisors Australia (GPSA). Practice bulk billing patterns were explored by rurality, state or territory and practice size at univariate level before a multivariate logistic regression model was done, including the statistically significant variables. Nationally, bulk billing rates for general practice non-referred attendances increased over 2012-2019 from 82% to 86% but declined slightly in Modified Monash Model (MMM)2&minus;7 (rural areas) at the end of this period. Further, bulk billing rates varied by rurality, and were highest in very remote (MMM7) (89-91%) and metropolitan areas (MMM1) (83-87%) and lowest in regional centres (MMM2) (76-82%) over this period. The results from the GPSA survey concurred with national data, showing that the proportion of practices bulk billing all patients was highest in metropolitan locations (28%) and lowest in regional centres and large rural towns (MMM2&minus;3) (16%). Smaller practices (five or fewer general practitioners) were more likely to bulk bill all patients than were larger ones (six or more general practitioners). Multivariate modelling showed that bulk billing all patients was statistically significantly (p<0.05) less likely for larger practices compared with smaller ones, and for rural practices (MMM2&minus;7) compared with those in metropolitan areas. Mandatory bulk billing policies should accommodate the fact that bulk billing varies by context, including rurality and the size of a practice, and has been decreasing in rural areas over recent years. Rapidly pivoting to bulk billing only service models may put pressure on rural and large practices unless they have time to adjust their business models and have ways to offset the loss of billings. Policies that allow for a range of billing arrangements may be important for practices to fit billings to their local context of care, including in rural settings, thereby supporting business viability and the availability of sustainable primary care services.

Medical students value-adding to general practice.

Medical students can make valuable contributions to patient care during clinical placements. The aim of this study was to investigate student perceptions of the value of general practice placements for their learning, and their sense of contribution during their placements. The study used a qualitative design to gather in-depth student perspectives on learning and contributions, using focus groups of final-year medical students on general practice placement. Thirteen students participated in one of three focus groups. Students reported valuable learning affordances in general practice and identified contributions to improved workflow, rapport-building, patient education, encouraging clinician reflection and shared learning between general practitioner and student. Student perspectives of value-adding on general practice placements, and a deeper understanding of these learning environments, may enable general practice supervisors to facilitate placements that maximise these benefits.

Transitions in general practice training: quantifying epidemiological variation in trainees\u2019 experiences and clinical behaviours

BackgroundGeneral Practice training in Australia is delivered through the apprenticeship model. General Practice supervisors support trainees transitioning from hospital-based work towards competent independent community-based practice. The timing and manner in which support should be provided is still not well understood. This study aimed to establish the variation in clinical and educational experiences and behaviours, and location, of general practice trainees’ consultations by stage of their vocational training. It was hypothesised that change is greater in earlier stages of training.MethodsA cross-sectional analysis of data (2010–2018) from the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing cohort study of Australian GP registrars’ in-consultation clinical and educational experience and behaviours. Multinomial logistic regression assessed the association of demographic, educational, and clinical factors in different stages of training. The outcome factor was the training term.ResultsTwo thousand four hundred sixteen registrars contributed data for 321,414 patient consultations. For several important variables (seeing patients with chronic disease; new patients; seeking in-consultation information or assistance; ordering pathology and imaging; and working in a small or regional practice), odds ratios were considerably greater for comparisons of Term 1 and 3, relative to comparisons of Term 2 and 3.ConclusionDifferences experienced in demographic, clinical and educational factors are significantly more pronounced earlier in registrars’ training. This finding has educational and training implications with respect to resource allocation, trainee supervision and curriculum design. Sociocultural learning theory enables an understanding of the impact of transitions on, and how to support, general practice trainees and supervisors.

PQRST: A framework for case discussion and practice-based teaching in general practice training.

One of the most important roles of the general practice supervisor is that of clinical teacher. Practice-based teaching comprises formal (structured) and informal (opportunistic) teaching, both ofwhich are primarily based on case discussion. There is no simple framework to guide effective case discussion across both forms of practice-based teaching. In this article, a newfive-stage model ofcase discussion is proposed: PQRST. Thestages are: P - What is the patient's problem?, Q - What is the registrar's question?, R - How well does the registrar reason?, S- What is the solution?, and T - What can be taught? The PQRST framework has many benefits. It is a simple framework for case discussion for both formal and informal teaching settings. It emphasises the assessment of clinical reasoning, is time efficient and explicitly prioritises patient and registrar safety. Additionally, it is adaptable for registrars at all levels of training and/or competence.

Preceptorship scheme for newly qualified physician associates working in general practice in Sheffield

We describe a preceptorship model that was initiated in March 2018 for newly qualified physician associates (PAs) in primary care in Sheffield, UK. The scheme enabled part funding for four band 6 preceptorship posts initially, alongside fortnightly teaching and mentorship by the preceptorship lead and a senior PA external to the employer. The number of posts had increased to 20 at the time of writing, due to the success of the scheme. We discuss how the scheme arose, and feedback from the general practice (GP) supervisors and the preceptorship PAs. The advantages of an external senior GP PA mentoring the preceptorship PA is highlighted, and this scheme may be the first of its kind to initiate this level of mentorship. A 'preceptorship scale' is suggested, which may aid employers in thinking about in-house support for this new member of their team in their first year of practice.

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.

Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and 'patient entrustment' (patient confidence in the trainee's clinical management).Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.

A ‘call for help’ list for Australian general practice registrars

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. The study used a qualitative approach involving 75 registrars, supervisors and medical educators from seven focus groups in Victoria and Tasmania. 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. 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.

Communication between primary and secondary care: deficits and danger.

Timely and accurate communication between primary and secondary care is essential for delivering high-quality patient care. The aim of this study is to evaluate the content contained in both referral and response letters between primary and secondary care and measure this against the recommended national guidelines. Using an observational design, senior medical students and their general practice supervisors applied practice management software to identify 100 randomly selected adults, aged greater than 50 years, from a generated list of consults over a 2-year period (2013-2015). All data included in referral and response letters for these adults were examined and compared with the gold standard templates that were informed by international guidelines. Data from 3293 referral letters and 2468 response letters from 68 general practices and 17 hospitals were analysed. The median time that had elapsed between a patient being referred and receiving a response letter was 4 weeks, ranging from 1 week for Emergency Department referral letters to 7 weeks for orthopaedic surgery referral letters. Referral letters included the reason for referral (98%), history of complaint (90%) and current medications (82%). Less commonly included were management prior to referral (65%) and medication allergies (57%). The majority of response letters included information on investigations (73%), results (70%) and follow-up plan (85%). Less commonly, response letters included medication changes (30%), medication lists (33%) and secondary diagnoses (13%). Future research should be aimed at developing robust strategies to addressing communication gaps reported in this study.

Promoting professional behaviour in general practitioner training practices: The views of practice managers.

General practitioners (GPs) are required by the Australian professional colleges of general practice - The Royal Australian College of General Practitioners and The Australian College of Rural and Remote Medicine - to practise a high standard of professional behaviour. General practice registrars (GPRs) learn this in their training practices not only from their general practice supervisors, but also the practice managers (PMs). Little is known of PMs' views of the meaning ofthe term 'professional behaviour' andhow they view their role in GPR education. Nineteen semi-structured interviews with PMs were conducted. Saturation was reached and consensus achieved on the analysis. PMs held nuanced views on the meaning of the term 'professional behaviour' and actively promoted and modelled this to their staff, including GPRs. PMs believed they had a role in GPR education. Practice managers are well placed to model and teach professional behaviour, and their skills should be further used to educate GPRs.

‘Your head can literally be spinning’: A qualitative study of general practice supervisors’ professional identity

Supervisors have an integral and demanding role in general practice vocational training. Becoming a supervisor involves expanding a ‘clinician’ professional identity to include ‘supervisor’. Little is known about what contributes to the development of supervisor identity; knowing this could inform effective training and support. This study explored the experiences and perceptions of supervisors to understand what contributes to their professional identity formation. Transcripts of 15 semi-structured interviews with general practice supervisors were analysed using Wenger’s ‘community of practice’ theoretical framework as an analytic lens. Developing a supervisor identity involved four interdependent features: learning the skills of being a supervisor; belonging in the role of supervisor; finding meaning in supervision; and balancing the role of supervisor and clinician. Relationships are fundamental to the development of the general practice supervisor identity. Important relationships are those the supervisor has with their registrar, their practice community, the training program and other supervisors. These relationships support and reinforce their supervisor role. It is important to adequately recognise, protect and cultivate a program that values these relationships.

Implementation of workplace-based assessment in general practice

ABSTRACTBackground: Workplace-based assessment (WPBA) is widely accepted, but few studies have investigated implementation issues during general practice (GP) placements. This study explored possible barriers and identified key elements for successful implementation of a WPBA-programme in Danish GP specialist training.Methods: Supervisors had attended a one-day course in WPBA and trainees had received a short introduction. Questionnaires on experiences with implementation of WPBA were distributed to 106 GP supervisors and 110 trainees after the rotation was finished.Results: The response rate was 61/96 (64%) for trainees and 67/94 (71%) for supervisors. Supervisors were generally more positive towards WPBA and saw fewer barriers than trainees. Lack of planning was most often reported as an impediment to WPBA. Supervisors did not identify trainees’ uneasiness of being observed as a problem as often as trainees. A total of 34% of trainees reported uneasiness as an obstacle to WPBA.Conclusions: It seems that the education of supervisors positively influenced supervisors’ perception and use of WPBA. Adequate planning of WPBA may be just as big a problem as assigning the time. Further investigations on the impact of education on trainees’ perception of WPBA are needed.

'I'm never going to change unless someone tells me I need to': fostering feedback dialogue between general practice supervisors and registrars

Feedback is often unidirectional and focused on learners receiving feedback. Learning relationships are viewed as influential to promoting feedback dialogue. The aim of this study was to explore factors that facilitate or impede feedback between general practice supervisors and registrars. An in-depth qualitative study was conducted. Data collection featured semistructured interviews with registrars (n = 9) and supervisors (n = 5). Interviews were audio recorded and analysed interpretatively. Feedback was affected by personal (i.e. resilience, humility), relational (i.e. strength of supervisory relationship, power differentials) and contextual (i.e. culture) factors. Registrars are not accustomed to providing feedback and supervisors do not typically request feedback. Past feedback experiences affect registrar engagement in feedback exchanges. A culture of feedback dialogue within training organisations and training practices is essential. Power imbalance needs to be addressed, particularly for feedback by registrars. Strategies to develop feedback skills and promote an open feedback culture are essential.

Factors related to rural general practitioners supervising general practice registrars in Australia: A national cross-sectional study.

General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars. Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data. Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, andsupervising medical students andinterns. Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

Adapting the supervisory relationship measure for general medical practice

BackgroundThe relationship between general practice (GP) supervisors and registrars is a critical component in effective training for the next generation of medical practitioners. Despite the importance of the relational aspect of clinical education, most evaluation has traditionally occurred from the perspective of the registrar only. As such, no validated tools exist to measure the quality of the supervisory relationship from the perspective of the supervisor. This paper presents an adaptation and validation of the clinical psychology supervisory relationship measure (Pearce et al, Br J Clin Psychol 52:249–68, 2013) for GP supervisors in an Australian context.MethodFollowing an Expert Group review and adaptation of the items, 338 GP supervisors completed the adapted tool.ResultsUsing principal components analysis and Procrustes confirmatory rotation, an optimal three-component model of supervisory relationship was identified, reflecting measures of Safe base (α = .96), Supervisor investment (α = .85), and Registrar professionalism (α = .94).ConclusionsThe general practice supervisory relationship measure (GP-SRM) demonstrated excellent model fit, high internal consistency, and was theoretically consistent with the original tool. Implications for clinical education and future research are presented.

Supporting Aboriginal and Torres Strait islander cultural educators and cultural mentors in Australian general practice education

BackgroundPromoting cultural competence of health professionals working with Aboriginal and Torres Strait Islander communities is key to improving health outcomes. Cultural Educators and Cultural Mentors (CE/ CMs) have critical roles in Australian general practice training, yet these are not well understood.MethodsGuided by a CE/CM Network, our research team including experienced CE/CMs, used surveys and semi-structured interviews to explore these roles and investigate best practice in employment and support. Participants sampled from stakeholders involved in general practice education across Australia included CE/CMs, Medical Educators, General Practice Supervisors and Registrars, and representatives of Regional Training Organisations, Indigenous Health Training Posts and other key organisations. We undertook thematic analysis using a framework approach, refined further in team discussions that privileged views of CE/ CM members.ResultsParticipants comprised 95 interviewees and 55 survey respondents. We organised our findings under three overarching themes: understandings about cultural education and mentoring; employment and support of CE/CMs; and delivery and evaluation of cultural education and mentoring. Our findings supported a central role for Aboriginal and Torres Strait Islander CE/CMs in face-to-face Registrar education about culture and history and related impacts on health and healthcare. Cultural education was reported to provide base-line learning as preparation for clinical practice whilst cultural mentoring was seen as longitudinal, relationship-based learning. Mentoring was particularly valued by Registrars working in Aboriginal and Torres Strait Islander communities.Challenges described with employment and support included difficulties in finding people with skills and authority to undertake this demanding work. Remuneration was problematic, particularly for CMs whose work-time is difficult to quantify, and who are often employed in other roles and sometimes not paid. Other improved support recommended included appropriate employment terms and conditions, flexibility in role definitions, and professional development. Recommendations concerning implementation and evaluation included valuing of cultural education, greater provision of mentoring, partnerships with Medical Educators, and engagement of CE/CMs in rigorous evaluation and assessment processes.ConclusionsOur research highlights the importance of the unique CE/CM roles and describes challenges in sustaining them. Professional and organisational support is needed to ensure delivery of respectful and effective cultural education within general practitioner training.

Patterns of direct observation and their impact during residency: general practice supervisors' views.

ContextDirect observation (DO) of residents’ performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome‐based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME.MethodsConstructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included.ResultsWe found four patterns of DO of technical skills: initial planned DO sessions; resident‐initiated ad hoc DO; supervisor‐initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents’ learning.ConclusionsDirect observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side‐effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.