Transitions, adaptation and uncertainty in general practice training

Transitions are a process where individuals adapt in response to changing clinical practice and responsibilities.¹ General practice registrars (hereafter registrars) constantly undergo psychological, social and educational adaptation in response to changing contexts, geographies, responsibilities, interpersonal relationships and identity.² This paper focuses on the initial adjustment to general practice faced by registrars, within the context of the difficulties registrars face when navigating uncertainty. Practical strategies for registrars, supervisors and medical educators are proposed and summarised in three overarching principles (Figure 1). Although this paper focuses on transitions faced during general practice training, transitions feature throughout a general practitioner’s (GP) career. Accordingly, equipping registrars to successfully navigate transitions both within their training and in the longer term is essential for professional and personal wellbeing over their career.

The adjustment to general practice

The initial adjustment registrars face when entering the specialty from the hospital system is particularly stark. General practice training is characterised by unique clinical and professional environments with exposure to a wide array of problems, chronic disease management, independence in decision making, time pressure, uncertainty and limited availability of resources and supervision. GPs have an ever-increasing scope of practice with greater exposure to complex medical and surgical care.^2,3 Clinics are often geographically dispersed, with most training occurring in small, usually private, practices in an apprenticeship-like model.¹ A major component of the transition process is adaptation to general practice training and work-specific stressors, with a view to developing and adopting the professional identity of a GP.⁴ The very start of general practice training is the most challenging point of the transition process, associated with tension, anxiety, frustration and uncertainty.^5,6 How registrars navigate this adaptation is critical to the sustainability of a registrar’s career. Effective adaptation promotes the development of registrars’ self-efficacy and confidence as GPs.⁷ Conversely, those who struggle with this process experience burnout and reduced motivation.^8,9 Understandably, transition periods have historically been viewed as stressful and associated with negative emotions.¹⁰ Consistent with this, the autonomy and responsibility entrusted to registrars brings a potentially greater workload and risk of burnout;^2,11,12 however, these outcomes can be avoided.

Transitions and uncertainty

The high degree of uncertainty is a prominent challenge in the initial adjustment to general practice – and persists throughout the working life of a GP. Working in primary care arguably introduces high levels of uncertainty due to the early and undifferentiated nature of symptoms experienced by patients.¹³ Indeed, uncertainty is an inevitable and defining feature of general practice.^13–15 The Royal Australian College of General Practitioners (RACGP) recognises understanding and ‘tolerating’ uncertainty as a core clinical competency;¹⁶ however, managing diagnostic uncertainty is often perceived negatively by registrars.¹⁷

Uncertainty in general practice

It is worthwhile first considering the nature of uncertainty in general practice and why building one’s tolerance of it is so critical for registrars’ development. To many, it would be obvious that this uncertainty arises from the undifferentiated and unorganised nature of problem presentation.¹⁸ Uncertainty, however, is multifaceted. Beresford offers a framework of uncertainty, describing three types: (1) technical (due to limited data or skill); (2) the personal (describing patient-side factors and considerations); and (3) the conceptual (considering the application of guidelines, criteria and protocols to real-world clinical scenarios).¹⁹ Uncertainty in general practice often encompasses all three domains simultaneously; that is, beyond purely technical challenges (eg diagnostic and therapeutic decisions), patients and their specific sociocultural contexts present novel and unique challenges for registrars.

Navigating this multifaceted uncertainty is difficult. Registrars are taught through their medical training that certainty is valued over uncertainty, and standard practices aim to minimise or eliminate uncertainty.²⁰ Such attitudes can lead to less helpful approaches to contain uncertainty by denying its existence, over-relying on protocols and evidence-based medicine,²¹ adopting peers’ practice,¹⁵ or relying on heuristics (cognitive shortcuts).

It would not be too bold to suggest that navigating uncertainty has direct implications for the quintuple aims of healthcare, affecting patients, population health, sustainable costs of healthcare, health equity and practitioner wellbeing.²² The consequences of uncertainty intolerance are profound. The stress from being unable to manage uncertainty can precipitate clinician burnout and depression.²³ If the maladaptive responses to uncertainty perpetuate a negative spiral, there is increased psychological distress,²⁴ loss of self-compassion,²⁵ and greater career dissatisfaction and disengagement.¹⁵ Clinicians with a higher intolerance of uncertainty are also more likely to avoid patients with complex needs, contributing to health inequities.²⁶ Patients can also suffer as a result of increased errors and undergoing unnecessary testing, interventions and referral, which can add to healthcare-associated costs.⁸ In pursuing the ‘right’ answer or rigidly adhering to protocols and evidence-based medicine, there is a risk of oversimplifying the rich, iterative nature of clinical reasoning into a mechanistic process, inhibiting humanistic, individualised patient-centred care that is a hallmark of general practice.²⁰

Exposure to clinical practice

The good news for registrars is that it gets better. Experience is independently associated with greater tolerance of uncertainty, so registrars can expect to become more comfortable with uncertainty as they progress through training.²⁷ Greater time spent in supervised practice is associated with increased confidence and coverage of clinical skill deficits.^28,29 The diversity of patient presentations and the workload of general practice has previously been well received by those in supportive communities of practice with like-minded colleagues.³⁰ Conversely, this same diversity and workload represents a risk for burnout and exhaustion when registrars perceive themselves as being surrounded by unhelpful colleagues or colleagues experiencing burnout.³¹ Barriers to successful adaptation to general practice include being overworked due to understaffing, an imbalance in patient presentation types, and where teaching and supervision cannot be adequately provided.³²

Acceptance of uncertainty

There are strategies besides ‘waiting it out’ to build one’s uncertainty tolerance. First, registrars can modify their expectations about certainty.^27,33 Absolute certainty in defining and managing clinical problems is rare and not a prerequisite to patient treatment. In the absence of a ‘clear’ diagnosis, helping a patient prioritise and solve problems, and effectively manage symptoms over several consultations in a manner specific to them, might be better than pursing an elusive concrete diagnosis.

Acknowledging and accepting uncertainty and communicating this with colleagues and patients is self-protective and even motivational, encouraging information-seeking, the development of practical solutions or a considered selection of preventive, diagnostic and therapeutic actions.^15,34,35 By attending systematically to uncertainty and relating to it in a self-conscious way, knowledge can be obtained through a process of enquiry.³⁶ Lonergan describes three levels in this process, including: (1) experiencing: reviewing data, both available and unavailable; (2) understanding: asking, and acting on, questions based on the information to clarify what is known and unknown; and (3) judging: committing to a particular interpretation.³⁶ Woven through these levels is the context in which information is presented. Consider the causes of chest pain in an older patient with vasculopathy and multiple cardiovascular risk factors such as smoking and diabetes versus in a younger, otherwise healthy patient who has recently taken up weightlifting. Although accepting a broad range of possibilities – from the trivial to the lethal – could be present in either presentation, our individual heuristics and presuppositions will influence our management of the uncertainty present, and inform our treatment decisions.

Connection and support

The context, connection and support (Figure 1) surrounding the transition to independent specialist practice is critical. Opportunities to share knowledge with other GPs and working with positive role models helps registrars navigate clinical, ethical and professional challenges. Conversely, working with unsupportive peers and supervisors who are experiencing burnout can exacerbate feelings of professional isolation.^31,37 Importantly, connection is also important in shaping registrars’ perceptions of their workloads. To help the adaptation to general practice work, it is important to develop supportive professional and personal relationships. These relationships extend beyond the period of training, into work as an independent specialist. This network can include a like-minded community of practice with other registrars and specialists, both GP and non-GP. Having connections with, and being in proximity to, support structures external to the workplace, such as friends and family, is also of great importance in the transition period.

Another method of managing uncertainty is via shared decision making. This is where the patient and clinician work together to make healthcare decisions. In verbalising the analytical process and explicitly highlighting uncertainty (which itself is an ethical imperative¹³), the clinician is no longer burdened by having sole responsibility of care. Shared decision making also encourages a deeper understanding of the patient context and allows for safety netting to be discussed, which are both further strategies to mitigate the impact of uncertainty.¹³

Conclusion

Defining an ‘ideal’ transition to independent general practice work as the absence of negative experiences would be counterproductive. A more realistic perspective recognises the transitions undertaken in training as challenging but formative. These experiences provide motivation for adaptation with growth in confidence in both clinical and non-clinical tasks and eventually adopting the professional identity as a GP. Acknowledging one’s limits, declining outright responsibility for the unsolvable and unknowable, and identifying when problems are progressing beyond personal capacity are critical skills. Recognising the challenges of the transition process and the ubiquity of stressors such as uncertainty is a key step to an effective adjustment to general practice and a sustainable career in the specialty.

Key points

• Encountering transitions, uncertainty and adapting to general practice is inevitable.
• Individual responses to these factors are shaped by the learning environment.
• The perceptions of transitions are improved with time spent in supported training.
• Seeking support and perspectives from others helps ease the adjustment to general practice.
• Learning to accept transitions, adaptations and uncertainty takes time and support.