Planning, Learning & Teaching
Assessing a GP registrar's learning needs
The process of assessing a GP registrar's learning needs involves finding out what the GPR would like to learn during their time in your practice. It is an important process that needs to occur early in the term. All GP registrars are expected to think about their learning needs and to develop a personal learning plan. They are provided with information about learning plans before commencing their GP terms. In addition the GP supervisor needs to think about the practice needs and the nature of their practice.
For example a GP registrar may indicate that they need to learn more about managing elderly patients, yet your practice in located in a new area that predominately sees children and young families, so this particular learning need may not be able to be met during this term. Furthermore you may discover that when you inform the GPR that they have been scheduled to run the practice immunisation clinic for the afternoon and they have never given a child an injection.
The time spent discussing learning needs and developing a learning plan is useful for both the GP registrar and GP supervisor as it creates a framework on which to structure the learning and teaching and in addition helps to foster a productive adult learning environment. Remember that learning plans are not static documents they should be reviewed during the term.
It is important to note that GP registrars have experienced many years of learning and teaching by the time they reach their GP term and most will have moved from being a dependant learner who responds best to a didactic teaching style to an interested learner who responds best to a teacher who is a motivator and facilitator of learning. Ultimately our aim is for GP registrars to become self-directed learners where the role of the teacher is often to delegate the task of learning back to the learner.
All learners are different but it is useful to note the following points.
- Learning is increased when learners are actively involved rather than passive onlookers.
- Learning is increased when learners receive immediate feedback about their performance.
- Principles which the learners discover themselves are usually understood more clearly, retained longer and applied more effectively.
- Learning is increased when the learner perceives that the information is relevant and meaningful.
- It is important to allow time for reflection.
Practice-Based teaching sessions
Once the learning plan has been developed the next task is to think about the variety of methods that can be utilised in the planned practice-based teaching sessions.
Some useful teaching methods include.
Case review Sessions
This is the most frequently utilised teaching method and usually occurs because a GP registrar will want to discuss a particular patient with the GP supervisor. This type of case review is obviously important because it meets an immediate learning need for the GP registrar.
Case review can also take a more structured format as well, commonly referred to as:
Structured Random Case Review, this is a variation on case-based discussion where cases seen by the GP registrar are selected at random. This random nature of selection has the advantage of bringing to the teaching session cases and issues that the GP registrar may not have been aware of at the time and may reveal issues not yet recognised as important.
The case discussion process can then follow a thematic pattern. There are a number of themes at different stages of the consultation that can often be identified, for example
Beginning
- Engagement
- First impressions
- Presenting symptoms
- Why the patient had come to see the doctor at this particular time.
Middle
- Context of the consultation, relevant issues
- Systems review, what was required?
- Patient's perspective (their feeling, ideas, fears & expectations)
End
- Information transfer, explanations, patient understanding
- Adherence
- Being rational, investigations, prescribing, use of specialists & community resources
- Safety-netting
- Follow-up
General Issues
- Time management
- Preventative issues
- Evidence based medicine.
GP registrars should be encouraged to reflect on the cases discussed and to think about how they will address any learning gaps that may have been identified. GP registrars are required to present two case discussions as part of their learning portfolio; these sessions will provide opportunities for the GP registrar to identify suitable cases.
Case Audit
This is another form of structured case review, but in this session a particular learning area is identified and then a series of cases are reviewed and discussed with the GP registrar focussing on the identified learning area.
For example the GP registrar may identify that they have experienced difficulty in identifying and implementing opportunistic prevention and health promotion. The cases from a particular day or session could be reviewed with the specific focus being on opportunistic prevention and health promotion. The RACGP guidelines for preventative activities in General practice could be utilised as a resource in this session
The GP supervisor could also use role-play to demonstrate the skills in communicating prevention and health promotion to the patient.
Referral letter review
This is a useful exercise for a teaching session and can achieve the following aims;
- Provide feedback to the GP registrar about the content and quality of their referral letters.
- Stimulate discussion about when to use a specialist and specialist services available in the area.
- Reviewing the usefulness of the opinion from the specialist.
- Introducing the concept of the general practitioner as a co-ordinator of health care for the patient and patient advocacy.
During this session a copy of the referral letter and the specialist reply are reviewed together. The GP supervisor should also bring some of their referral letters to the session.
Issues that could be raised include:
- Was the referral necessary? Could the patient have been managed by the general practitioner? If so what knowledge and skills would be needed?
- Were the specialist's findings and conclusions similar to the GP registrars? If not what was different and what does the GP registrar think about this, have they learnt anything?
- Were there any investigations arranged by the specialist about which the GP registrar needs more knowledge.
- Is there a need for the GP registrar to gain more knowledge about the treatment recommended by the specialist?
- Was the specialist's opinion helpful in the ongoing management of the patient?
- What role has the GP registrar got in the ongoing management of the patients?
Clinical Audit
It is useful to introduce the GP registrars to the concepts and processes involved in performing clinical audits. The GP registrars are required to complete a clinical audit project as part of their training requirements, devoting a teaching session to discussing this would be very useful for the GP registrar.
This session could also introduce the GP registrar to organisations such as the National Prescribing Service, through discussion of the various NPS audit activities it also provides and opportunity for GP registrars to become familiar with the role that Divisions of General Practice have in assisting GPs to complete audit activities. In addition it can increase the GP registrar awareness of the QA and CPD program activities and the role of clinical audit.
IGPE currently has two audit projects that the GP registrars may choose to undertake.
- Nutrition checklist
- Hypertension
Further information about these audit projects is available in the Project Information Sheet or from IGPE.
Direct Observation of GP registrars
Observing your registrar's consultations either directly by sitting in or by videotaping and providing feedback on those consultations should be an integral part of your structured teaching. It is also important for the GP registrar to spend time sitting-in with you.
What is direct Observation?
Direct observation is the observing and giving feedback on clinical skills in the practice environment. It is one of the most valuable ways for GP registrars to learn clinical skills and it is also the only way to really assess how a GP registrar is performing with patients.
If carried out regularly it engenders an environment where reflection on practice is encouraged and allows the supervisor to give specific feedback to the registrar that enables them to continue to improve in their clinical performance (1).
It has been said by educator and philosopher John Dewey that “all learning begins when our comfortable ideas turn out to be inadequate” (2). Through direct observation and feedback GP supervisors can create this constructive discomfort and help facilitate learning.
The advantages of direct observation.
- Able to see how GP registrars perform with patients.
- Able to assess how GP registrars are progressing over time.
- Powerful way to teach clinical and consulting skills and display attitudes and values.
- Able to give feedback that provides the GP registrar with insight about what they actually do and information about the possible consequences of their actions.
- Facilitate completion of the end of term assessment form on the GP registrar.
The barriers to direct observation
- Lack of time
- The patients always try and engage the GP supervisor rather that the registrar and this can undermine the GP registrar
- The GP registrar does not like it
- The GP supervisor does not like it
Some tips for successful direct observations sessions
- Make time - Teaching time requires planning, it is important to try and make direct observation sessions part of the practice culture and to schedule time into the appointment system so that direct observation can occur. It is recognised that this sometimes creates a financial loss, which is why IGPE have developed incentive payments for GP supervisors who undertake regular direct observation. Please speak to the IGPE office regarding these.
- Set the scene with your GP registrar - It is helpful to discuss your plans for direct observation with the GP registrar, discuss how these sessions will be conducted and clarify the ‘ground rules' for the session. This is especially important for GP registrars who may not have been observed before (eg Basic GP registrars before their first clinical teaching visit). These sessions are intended to be formative (ie provide the GP registrar with information, examples and strategies for improving their clinical and consulting skills. However if a GP supervisor identifies problems or has significant concerns about the GP registrar's performance then this should be discussed with their medical educator so that an appropriate plan can be implemented.
- Observing - It is probably best that the observer's chair is out of the line of sight of the patient and the registrar so that the focus is on the learner not the patient. Avoiding eye contact with the patient helps them to remain engaged with the GP registrar. This is especially so when the GP supervisor is observing and the patient is known to the observing doctor. It is also useful to adopt the principle that you will not interrupt unless directly asked by the GP registrar or if you feel that they are about to do something that is unsafe. It is useful to discuss with the registrar what your action will be in this situation. Eg send the patient to collect a urine sample (if appropriate), ask the GP registrar if it is okay to chat outside for a minute. Otherwise it is better to leave comments and feedback until after the consultation.
- Giving Feedback - This is the most important aspect of a direct observation session and when successful will enable the GP registrar to improve in their future performance. More information about giving feedback is provided.
- Develop some skills in questioning - Good questioning is the key to good teaching and questions that raise the GP registrar's awareness of the clinical process are often the most useful. Eg …”what do you think is going on here?” “What led you to that diagnosis?”
- Learning the skills - There are a number of opinions as to whether feedback ensuing from direct observation should concentrate on content or process issues in the consultation. Proponents of process tend to argue that feedback on content can occur in so many other situations where process has to be neglected. However without accurate comments on content the registrar is doomed to repeat errors in history, examination, diagnosis and management. When giving feedback it is easier to give the ‘what' is wrong than to provide a method of getting things right. Needless to say as in most debates truth lies on both sides of the argument and so it has to be said that both content and process are important. The consultation provides the best opportunity to teach a GP registrar the skills of patient centred medicine and for the GP supervisor to see how the GP registrar uses these skills during a consultation.
References:
(1) Holmwood C. Direct Observation a primer for supervisors of doctors in training. Australian Family Physician. Vol 27 No.1 January 1998
(2) Russel G. An eagle eye on the trainee. (article) Therapy Update. Australian Doctor May 2006.
The following teaching tips and tools were originally developed for IGPE clinical teaching visitors and are useful during direct observation sessions.
Practical Procedure Teaching Sessions
It is always useful to determine if a GP registrar is interested in learning practical procedures early in the term, because these sessions need to be planned in advance otherwise learning and teaching opportunities may be missed.
There are many skills required to perform a procedure and it is useful to think about these prior to the session.
These include:
- Knowledge - what knowledge is required in order to successfully perform the procedure? Eg:
- relevant anatomy
- indications and contraindications
- local anaesthetic use
- complications etc.
- Skills - what skills are required to successfully perform the procedure (eg preparation, actual technique, manual dexterity)
- Communication - what information needs to be communicated to the patient? (eg consent, patient comfort).
- Attitudes - is the GP registrar aware of their limitations and when to get help?
A useful approach when learning procedural skills:
- Discuss the important aspects of performing the procedure with the GP registrar, if possible demonstrate using models.
- Have the GP registrar observe you performing the procedure and then discuss this with the GP registrar. Have they identified any gaps in their knowledge, skills and/or attitudes?
- Observe the GP registrar performing the procedure and provide feedback.
- Practice the procedure as often as possible.
In Lake FR & Hamdorf JM. Teaching on the run tips 5: teaching as a skill. MJA vol 181 No6. 20th September 2004, the following model is used to demonstrate how practical skills are acquired.
Stages in acquiring skills, Practice makes perfect
In this model, the registrar has shifted from being “consciously incompetent” (realising they can't do it) to being “consciously competent” (being able to do it with great thought). Only with repeated practice will he or she be able to perform satisfactorily in a variety of situations.
During the IGPE based workshop program the following practical procedures are demonstrated using models:
- Cryotherapy
- Diathermy
- Excision of cysts and naevi
- Punch biopsy of the skin
- Management of ingrown toenails
- Intra-articular injection (shoulder, knee and wrist)
- Joint aspiration (knee)
- Pap smears
GP supervisors are welcome to attend any of these sessions.
Reference:
Lake FR & Hamdorf JM. Teaching on the run tips 5. Teaching as a skill. MJA Vol 181 (6). 20th September 2004.
