‘Feeling like a deer in the headlights’: A qualitative study of registrar experience in early general practice training

The transition for doctors from hospital to becoming general practitioners (GPs) is difficult. Most registrars have amassed a large amount of medical knowledge and skills, but in the general practice setting they face a patient with undifferentiated symptoms or concerns alone. The registrar needs to connect, as John Murtagh states, ‘the vast amount of accumulated medical knowledge with the art of communication’.¹ Given that general practice has its own curricula, consultation style, skillset and holistic approach to diagnosis and management, this can be challenging.²

This transition can be seen and understood theoretically in a number of ways, including as a personal journey of identity formation or as a process of learning. Professional identity formation involves learning and adopting the knowledge, skills, values and behaviours of that profession. It is a concept that has come into vogue within medical education circles.^3,4 The learning process is understood to be not only the transfer of knowledge and skills, but also a complex developmental activity that is context dependent. It is a social process that depends on participation and is relational in nature.⁵ The experiences of learning can be transformative⁶ and are linked to emotions, both positive and negative.⁷ Learning has also been described as moving from a position of ‘unconscious incompetence’, through ‘conscious incompetence’, to ‘conscious competence’ and, potentially, ‘unconscious competence’.⁸

The transitions from medical student to doctor^9–12 and from hospital doctor to independent consultant have been explored,¹³ but little research has looked specifically at the transition from hospital doctor to independent primary care practitioner.

This research is informed by the narrative paradigm, which is based on the idea that not only are humans storytellers,¹⁴ but stories and narrative are how humans make sense of their experiences and create a coherent meaningful self or identity.¹⁵ The underlying aim is based on a belief that by hearing the stories of the learners, and thus improving our understanding of this transition, we may improve the journey for subsequent registrars. Identifying shared key experiences may contribute to developments in the training program.

Methods

A narrative inquiry approach, which explores lived experience, was used.^16,17 Registrars kept a fortnightly audio-diary reflection (in two cases this was a written diary). This method has been used to explore the journey of medical students,⁹ hospital consultants¹³ and general practice supervisors.¹⁸ The reflections were supplemented by a semi-structured interview at the start and end of the term; these interviews were all undertaken by CB, who also sent reminders about the fortnightly reflections. The data are, in effect, a series of reflections from the registrars to CB, bookended by the interviews. All of these interviews and reflections were transcribed, anonymised and stored securely.

The process of analysis was undertaken by all members of the research team using a constant comparison method, a general inductive approach involving close attention to the recordings and transcriptions to gain an understanding of the data. The main researcher (CB) paired herself in turn with each member of the research team to analyse sections of the data. Themes generated through this work were brought back to the group for further discussion before agreement was reached on the major themes.¹⁹

Reflexivity

The initiative for the research came from DH, whose background is as a GP in an inner-city community health setting, which includes significant numbers of patients with mental health, substance use and homelessness issues. He has been a general practice supervisor for over 10 years and has consequently supervised many registrars in their first general practice term. His research training is a Master of Medical Anthropology. This background informs and potentially may bias the research. CB, whose PhD involved researching children’s learning, has a background in education and has substantial experience in science, technology, engineering and mathematics (STEM) education research and policy development. JP is an experienced GP who has worked in a variety of urban and rural settings. She is also a senior and very experienced medical educator and has been employed as a medical editor and writer.

Participants

Participants were registrars in the two Victorian general practice training organisations (Eastern Victoria GP Training and Murray City Country Coast GP Training) who were undertaking their first six-month general practice term. The recruitment process involved the two main researchers (DH and CB) attending the orientation workshops, explaining the nature of the research project and inviting registrars to be involved. Of this cohort of 25, 12 registrars were recruited.

The study was approved by the Human Research Ethics Committee of the University of Melbourne (Ethics ID: 1852051).

Results

Twelve participants were recruited. To maintain anonymity, demographic details are not presented; however, participants’ teaching practices included both urban and rural settings. There were both male and female participants, who were employed full time and part time, and their ages were between 27 and 40 years. In analysing the findings of the study, we were negotiating a tension between an individual’s unique narrative and finding commonalities between the registrars’ stories.

A summary of the themes is presented in Table 1. The themes are divided into a ‘learning’ journey and an ‘emotional and personal’ journey, which connects to two major ways of understanding transition, as described earlier. Themes from the learning journey are further divided into the ‘what’ and the ‘how’; that is, the content and process of learning.
 

Quotes are marked with gender (M for male, F for female) and age group. 

There is an abundance of reflections and stories that illustrate the above themes; however, the focus of this article is on details of the first two themes within the ‘personal’ journey, and the links to five themes within the ‘learning’ journey. The reason for this, apart from there being limited space to share these stories, is that these two themes not only epitomise the key change from working in hospitals but speak to potential registrar distress, an important current area of concern.

Anxiety and stress of early days

The striking feature or recurrent theme for all registrars in the early days and weeks of beginning work in general practice was the stress and anxiety associated with the realisation that that the registrar is making decisions independently, potentially for the first time in their careers:

I suppose the thing that I’ve struggled to get used to is the feeling like a deer in the headlights … complaints or diagnoses that you see in general practice, you just don’t come in contact with them in hospital. [F 20–29]

So I guess I started off very scared and nervous and then I think – maybe six weeks into the actual orientation or just being at the clinic – I started getting a little bit more comfortable. [M 30–39]

Weight of responsibility

Presentations are different to hospital practice, and registrars are anxious not to miss things or make mistakes, so they feel a significant ‘weight’ of responsibility:

In terms of perception of responsibility, I didn’t fully appreciate how as a GPT1 [general practice term one] registrar you are encouraged to practise independently, and your supervisor is there more if you have any questions or need direction. In this sense I’ve felt a greater sense of responsibility than I might have in the hospital system. [F 20–29]

I suppose the ongoing thing I’m struggling with in the context of feeling overwhelmed is still the concept of how much responsibility I feel and I suppose that is not missing the big, scary, life-threatening things … So, working out when something’s serious and when something’s not and not missing the scary malignancy stuff is still a hard thing. [F 20–29]

Awareness of limits of knowledge and skill

The anxiety, which relates to being responsible for the diagnosis and management of real patients, can be relieved by knowing the limits of one’s knowledge and skills, and by knowing when to ask for help from supervisors:

I think some of the things that stand out to me most would be the things that we see in general practice that need action straight away and then how to make that happen quickly. I think the key features for me have been recognising when I need to ask my supervisor something and recognising the things that you can’t just go yes, I’ll see you next week … I think mostly I’m okay with that but if I’m ever not sure then I ask the supervisor. [F 30–39]

Knowing the limits of one’s knowledge and skills can also be understood as ‘conscious incompetence’, a language that is familiar to registrars:

I feel as though I am currently on a long bridge between conscious incompetence and unconscious competence. I think I am competent in a safety aspect, I work safely, and am very comfortable asking my supervisors for help. [F 30–39]

Learning from supervisors using different levels of supervision

Registrar experience indicates the anxiety of the first few weeks is reduced if the patients seen by the registrar are also all presented to their supervisor (level one supervision). One registrar used the metaphor of being steered and of learning to take off:

I was steered a lot more in the beginning by the supervisors … it allowed a chance for me to present the information … and it allowed me to see how they approach the problem and gave me feedback as to where to go next. And then as the weeks went by the steering was more … ‘What do you think we should do?’ I guess as time went by further the steering was more so ‘Can I check this with you?’ It’s like a jet taking off, so … slowly and steadily you had to get to a level … [M 30–39]

One registrar experienced level two supervision; that is, every patient’s record was reviewed by the supervisor, though not necessarily before the patient left. This was also found to be very helpful in reducing the level of stress:

My supervisor had taken the time to read all my clinical notes and gave me, again, quite specific feedback on certain aspects of the consult. This is very very useful because at the moment, I’m not running past every single management plan with my supervisor so there are potentially certain times where there are aspects of care that I’ve missed and that’s been concerning for me at the end of a working day. So, it has been reassuring to know that he’s been keeping an eye on it. [F 20–29]

The majority of the registrars in this study experienced level three supervision, as most general practice registrars in the Australian General Practice Training program do. Level three supervision involves the general practice registrar asking their supervisor for help when they feel the need. It is the registrars’ choice whether to call the supervisor or not.

The ‘right’ approach

The anxiety about making a mistake, missing something and feeling daunted by the huge body of knowledge they do not know could also be relieved, the registrars realised, by learning the ‘right’ approach. The ‘right’ approach is one that is systematic, including a thorough history, examination and appropriate investigations, with follow-up and safety‑netting.

And I think, going on from that, I think just every patient that I see, it’s kind of becoming more clear that, even if you don’t know the answer, as long as you have the right approach to the patient in terms of, you know, rapport-building and taking a good history and doing a good examination, you know, and planning some investigations and planning some follow-up, it doesn’t really matter if you don’t have the answers because, you know, the appropriate approach will help you find them. [F 20–29]

Learning by doing and repetition

Much like other doctors, general practice registrars learn by doing and become more ‘comfortable’ through the repetition of seeing multiple patients, as well as seeing the same patients repeatedly:

I’ve learnt best on the job … actually doing the role, that’s then, by far, my best, sort of, learning. I guess that ‘doing’ part. And also, you know, you see a presentation and then you, sort of, look it up and work out what you need to do, or, you know, if you need to run it by someone. [F 20–29]

I think it’s going to be a continuum of learning. Probably something that I can’t just expect to pick up with a week or two of study. I think it’s going to be a progressive build-up of knowledge and being comfortable managing patients … [M 30–39]

I guess I’m learning a lot in the last couple of weeks because of these more complex presentations, and also because of getting to experience that real continuity of care; I’ve seen some patients half-a-dozen times – not always about the same issue, but sometimes about the same issue – and we keep exploring options until we figure out what’s going on and how we can help them. [F 20–29]

Social and relational learning

The anxieties associated with learning to be a GP can also be addressed by spending time with colleagues who are sharing that journey. All the registrars in this study mentioned the value of meeting with their peers at the out-of-practice workshops:

I think one of the major benefits of the workshops for me [was] debriefing with other trainees at my level … for me the benefits of the workshop were much more about that than any of the knowledge that we learnt – though that was sort of useful – but it was definitely about talking with other people who understood and were going through what you were going through … [F 20–29]

Talking to the other GPT ones [general practice term one registrars] at the training sessions every fortnight has helped a lot so far, it’s reassuring to know that we all have the same steep learning curve and insecurities at the moment. Which I guess is the reason why the fortnightly teaching sessions by MCCC [Murray City Country Coast] continue to be so helpful. [F 20–29]

One of the things that concerns me moving forwards … is this shift to webinar. I can see why it is done. Obviously, it is cheaper. I would just become less enthused on webinar and there are a few reasons for that: you miss out on the full social interaction of your peers … you are very isolated and lonely in your job – you miss out on catching up [with] your colleagues. To find out the difficulties that they are having compared to the difficulties that you are having and comparing the good things as well. [F 20–29]

Discussion

This study has highlighted the vital first few weeks of general practice training. The steep learning curve that the registrars experience connects deeply to an emotional and personal journey with a gradual reduction in stress and anxiety. The cognitive and the affective are intertwined. The anxiety, stress and weight of responsibility felt in the early days are alleviated by timely help from supervisors, by learning a systematic approach, through sharing experiences with colleagues and through experience.

In this study, two practices used initial levels of supervision that will identify unconscious incompetence. One practice had level one – all patients were presented to the supervisor while the patient was there. The other practice had level two – all patient records were reviewed by the supervisor. The registrars in those practices found that level of supervision reassuring and helpful. For most of the registrars, and in Australian general practice training generally, level three supervision operates; that is, the registrar calls the supervisor when they need help. There is an assumption of conscious incompetence; that is, the registrar knows when they do not know and will call the supervisor, who will respond appropriately. In this study, all registrars, whatever level of supervision they experienced, reported that they felt well supported by their supervisors and were able to get help when they needed to.

There has been recent discussion about this issue in regard to safety²⁰ and a call for consideration of closer supervision in early general practice training.²¹ This study offers data that support that call. Whatever level of supervision is involved, the importance of the supervisor, and the relationship between supervisor and registrar, in the learning process is acknowledged in the literature^22,23 and supported by this study.

The link between emotions and learning has been talked about since Aristotle’s time, and there has been a lot of research into this link.²⁴ As most people would understand from their own experience, it is not as simple as positive emotions contributing to improved learning. Experiencing negative emotion and getting out of our ‘comfort zones’ can stimulate strong learning.⁷

The emotional journey that the registrar goes through – from being nervous, anxious, a ‘deer in the headlights’, to one of becoming more ‘comfortable’ – accompanies the learning that is taking place; as the registrar becomes more knowledgeable and skilled, the anxiety level drops. This is not a linear process, as there can be key moments when the ‘penny drops’ and the level of anxiety drops, for example, the time when the registrar realises that they do not have to know everything, but if they follow the correct process, the ‘right’ approach, they will reach a satisfactory outcome.

The importance of helping general practice registrars manage the stressful early transition period becomes clear when there are reports about high levels of stress and increased levels of suicidal thoughts in doctors when compared with the general community. This involves younger doctors in particular – a recent Beyond Blue survey of doctors and medical students stated, ‘Young doctors appeared to be particularly vulnerable to poor mental health and high levels of stress’.²⁵

The understanding that becoming a GP is a complex social process is highlighted by the registrars’ stories of the sharing of their experiences with peers at face-to-face workshops. This is an important reminder not only of the crucial value of this process, but also of the necessity of it for healthy professional identity development. With the push to online learning, data from research such as this study remind program designers and deliverers of the need to understand the experience of the learners.

Implications for general practice training

This study focuses on the early weeks of general practice training and documents not only the stress and anxiety experienced by most registrars, but also what strategies can help registrars work through that stress. In particular, we document the importance of a registrar knowing the limits of their knowledge and skills and having the ability to access timely and authoritative supervision. The relationship between supervisor and registrars is clearly crucial to this ability. This study also raises the issue of potentially using level one and/or level two supervision for a period of time, as this is very effective in addressing registrar anxiety as well as identifying ‘unconscious incompetence’. Most countries with similar training programs have a period of level one supervision before moving to level two or three. This has never been the practice in Australia, but perhaps it should. The experience of registrars in the present study contributes to that debate.

The importance of face-to-face peer learning and registrars sharing their experiences with peers was described by all participants in this study. With the push to online and remote learning, this needs to be taken into account.

Limitations

The 12 registrars who participated in this study were in a cohort undertaking their first general practice term in the second half of the year, whereas most registrars begin their first term in the first half of the year, so the participants may differ from the larger group.

The strength of the thematic analytic approach is that it is possible to identify common experiences among the group of registrars, which may potentially identify areas of potential change. The weakness of this analysis is that the threads of narratives are not followed over time, potentially losing some of the richness and power of the stories.

This study focused on the early few stressful weeks of general practice training. Becoming a GP is a long and complex journey – indeed, many would say a lifelong journey – as learning and identity development are fluid, not fixed. The stress of the first few weeks is only part of the story.

Conclusion

Through the recording of fortnightly audio-diaries in their first six-month general practice term, this cohort of general practice registrars has given us a rich library of reflections, helping us understand ‘becoming a GP’ in Australia in the 21st century. This journey has been undertaken by many thousands of GPs over the years, and the findings would not be a surprise to them; however, the recording of the journey of a cohort of registrars has not been documented and summarised in this way before. The findings may help inform general practice training as it heads into a new era.