How can GP supervisors help registrars adapt to general practice?

Doug Hendrie

24/07/2019 3:57:51 PM

Moving from the structure and hierarchy of the hospital environment to the complexity, freedom and continuity of general practice can be challenging for young doctors. newsGP asks three GP supervisors their tips. 

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‘I am continually impressed by the quality of trainees that are choosing to become GP registrars.’
That’s Tasmanian GP Dr David Knowles, who in 2017 won the RACGP’s Rose-Hunt award and the General Practice Supervisor of the Year.
In his work as a supervisor, Dr Knowles has mentored many trainees as they shift mindsets from hospital to community medicine.
‘The biggest challenge is that general practice produces a different decision making environment where you are sitting in a room and have to make a decision for the patient at that time. It may not always be a hard decision but you are doing it more independently and without the hierarchy that exists in our hospital structures,’ he told newsGP.
‘Hospital hierarchies often mean junior doctors have less involvement in decision making and are more likely to be following orders.
‘In general practice you see patients in a certain allotted time and you are usually on a fee for service model. Hospitals do not usually work like this, so it takes time to get used to it.’
A key issue is that registrars often feel they have to solve all of their patients’ problems in a short span of time.
‘Often in hospital you feel as you have to solve everything immediately and make your decisions accordingly,’ Dr Knowles said.
‘[As a GP] you do not have to solve everything in 15 minutes. You can use time to your advantage.’ 
The shift from a team mentality to an individual practitioner can also be a challenge.
‘In hospitals trainees work as part of a team, and there is usually a power imbalance. There is always someone to ask and always somewhere to “hide”,’ he said.
‘Sitting is a room alone with a patient can be confronting and there is nowhere to hide. You are still part of a team but the team may be harder to see and ask questions of. If you let it, working in general practice can be lonely.’
Registrars often have very practical concerns early on, with questions around the IT systems which are very different to hospital software, as well as which specialists to refer to, how to order certain tests and what community supports are available locally.
Dr Knowles has found confidence in decision making is an area where registrars may need particular support early on. He argues that a practice-wide effort needs to be in place to support registrars as they find their footing.
‘[Registrars] are bright and usually well trained but they have often worked in an environment where they are not making many decisions,’ he said.
‘Getting to know the registrar is a whole of practice exercise. It is a great investment and is significant for risk minimisation. Many places will have not done this.’

Niroshi-article.jpgDr Niroshe Amarasekera is this year’s Victorian General Practice Supervisor of the Year.

Melbourne GP Dr Niroshe Amarasekera this year won the RACGP’s Victorian award for Supervisor of the Year.
She told newsGP there are many common issues registrars encounter as they move from hospital to general practice.
‘Common issues include fear of getting things wrong, unknown general practice presentations and  uncertainty around new presentations that need to be worked up, as in hospital they are often worked up by the time they get to the ward. Then there’s the Medicare Benefits Schedule, the Pharmaceutical Benefits Schedule and all the guidelines,’ she said. 
‘One of the most challenging but rewarding things is about getting them to have an identity as a GP. Often registrars have imposter syndrome at the start – or even towards the end of their training.’
For Dr Amarasekara, the transition involves a significant degree of deinstitutionalisation.
‘There is a lot of un-learning that needs to happen. Whilst there are guidelines and processes, there is never a black and white answer in general practice,’ she said
‘Often the registrar wants to walk away [from a discussion with their supervisor] with an “apply to practice” but unfortunately the answer in general practice is often, “it depends”.’
She said that the slower access to imaging and pathology testing was also a challenge.
‘Safety netting is important in general practice, as the patient leaves the room after the consultant, whereas the patient stays on the ward in hospital.’
Dr Amarasekara has seen registrars who have come to general practice after a difficult time during their hospital years.
‘Often the registrar comes to general practice suffering burn-out or from bullying. We need to boost their morale and give them the confidence that they are important and that we make a difference. Sometimes they can be disillusioned about medicine itself,’ she told newsGP.
‘The best support a supervisor can give to a registrar is to try to get to know them. Building that relationship where there is mutual respect is vital to learning. It is about challenging them enough so that they are outside their comfort zone, as this is where a lot of learning occurs, while also supporting them enough.
‘It’s almost like walking on a tightrope with the supervisor under the rope. You know they are there and can catch you if you slip, which gives you the confidence to walk that rope.’
Dr Amarasekara works as a medical educator one day a week. Over her time there, she’s watched as registrars fresh from hospital training find their feet.
‘I see them in their first term from hospital and then often see them again later,’ she said.
‘The growth in most registrars towards the end of training is profound. I really enjoy this longitudinal view as an educator.’
For the last three years, Sydney GP Dr Imaan Joshi has undertaken clinical training visits for registrars.
‘The single biggest thing I notice is what a big difference there is between the hospital system and community medicine,’ Dr Joshi told newsGP.
‘Trainees often feel they have to deal with everything the patient has in one consultation, hospital style. There’s a tendency to order investigations and imaging because it’s what you do in hospitals – you do every [test] just in case you miss something.’
Dr Joshi said many trainees find the shift challenging, particularly as they move from operating in a team to essentially working much of the day on their own. In addition, time management is a vital technique to learn.
‘The reality is, even with a diligent supervisor, most trainees are working essentially on their own and that can be very isolating,’ Dr Joshi said.
‘Supervisors will often tell registrars – you don’t have to work through everything a patient presents with unless it’s a quiet day. You learn strategies for breaking down their list [of issues] and say this is the time you’ve booked, what do you want to cover today and what will we defer till next time. The whole idea is that you will have an ongoing relationship with this person – it’s not a one stop shop.
‘The bread and butter of general practice is that you’re the one who helps them pick up the pieces, to normalise it and tell them what to expect with this new normal, to help with their recovery.’
Dr Joshi often talks to the registrars she visits about the importance of boundaries – and about how to say ‘no’.
Recently, she sat with a registrar in his first term in general practice when a patient came in seeking a drug with a high potential for addiction. Over the next 20 minutes, Dr Joshi watched, impressed, while the registrar held his ground in the face of escalating anger.
‘The patient amped up his anger and while I was prepared to jump in, this trainee did so well. He held to boundaries despite the red face that gave away his anxiety,’ she said.
‘The patient began talking in a manipulative way, and the trainee found ways around it, without engaging [or] getting agitated himself until the patient finally gave up. The demanding patient isn’t an uncommon presentation.’
Like Dr Amarasekara, Dr Joshi has seen many registrars who had a negative experience in hospitals and who have found general practice to be balm.
‘The number of people who hated hospital medicine but never realised there was an alternative – they come to general practice and are just so happy, away from the politics and bullying,’ she said.
‘I’ve known people who tried general practice after years of something else and then say, “why didn’t I do this sooner?”’

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newsGP weekly poll What area of medicine do you find most difficult to stay across the changing clinical evidence?

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Danny B   25/07/2019 6:53:29 AM

Great tips and advice. Love the positivity of these three GPs.

Dr Ian Light   25/07/2019 12:53:24 PM

For yourself and for the team around you being able to recognise and manage stable and unstable both physical and mental illness is really important for the competency and confidence zone .
General Practitioners need really good training in this .
Then you can feel you have time to sort out the great variety of presentations and follow up mechanisms you will need in general practice .