In-practice teaching resource

In-practice teaching resource

The future of general practice

Contents

Welcome 2 Introduction 3 Definitions

4

What teaching should I receive?

5

Summary of in-practice teaching standards

5

Racgp 5

Acrrm 6

Agpt program registrar on the Vocational Preparation Pathway

6

Registrar with the Remote Vocational Training Scheme

6

Content

6

How do I make the most of the teaching?

8

Learning plans

8

Learning styles

10

What can I do if my supervisor’s style does not match mine?

11

What is the difference between teaching and supervision?

11

Supervision

11

Teaching

12

Troubleshooting

13

References

13

Š2013 GPRA. All rights are reserved. All materials contained in this publication are protected by Australian copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission of General Practice Registrars Australia Ltd (GPRA) or in the case of third party material, the owner of that content. You may not alter or remove any trademark, copyright or other notice from copies of the publication. No part of this publication may be reproduced without prior permission and full acknowledgement of the source: In-practoice teaching guide, a publication of General Practice Registrars Australia.

All efforts have been made to ensure that material presented in this publication was correct at the time of printing and published in good faith. GPRA does not accept liability for the use of information within this publication. Due to the rapidly changing nature of the industry, GPRA does not make any warranty or guarantee concerning the accuracy or reliability of this content.

Welcome

The General Practice Registrars Australia In-Practice Teaching subcommittee (IPT subcommittee) was formed by GPRA in response to widespread general practice registrar concerns with both the quality and quantity of in-practice teaching (IPT) during vocational training. The subcommittee realised that in order to assist registrars to receive and make the best use of high quality, IPT according to the colleges’ guidelines, a new resource was required.

This resource was written in consultation with GP supervisors. The IPT subcommittee wish to acknowledge the many efforts of GP supervisors, recognising that much unrewarded work goes on behind the scenes to prepare for IPT sessions. The subcommittee thanks them for the time they have invested in, and their commitment to, developing the GPs of the future.

This resource is not intended to be prescriptive, but rather attempts to clarify the roles and responsibilities of the registrar as an adult learner, and the supervisor as an educator and mentor. It also suggests a number of avenues of recourse for registrars seeking assistance or who may have grievances.

The IPT subcommittee respectfully request that a hard copy be distributed to all GP registrars at or prior to the commencement of their GPT1 term. This document will also be made available online for universal and ongoing reference.

The IPT subcommittee invites feedback regarding this booklet, as well as discussion and suggestions around improvement of IPT for GP registrars.

2

This resource was written by Dr Emily Farrell, Dr Harry Kypreos, Dr Eugene Wong and Dr Edward Vergara

Introduction

General practice registrars spend the bulk of their training in a general practice setting.

Whilst regional training providers deliver a formal education program to GP registrars, arguably the majority of a GP registrar’s professional development occurs as a result of practice-based learning experiences. A vital part of this is the formal GP supervisor teaching that covers both the art, and the science of general practice. It is important to recognise that all teaching and learning inpractice is a combined, unique effort between two or more individuals. However, the registrar must be an active learner (and sometimes teacher), and is ultimately responsible for his or her own learning.

IPT comprises only a part – albeit a crucial part – of a GP registrar’s training. While in the general practice setting, registrars must place the various and varied opportunities for learning within the broader context of vocational and ongoing professional education.

As self-directed adult learners, it is imperative that GP registrars take overall responsibility for their own learning and actively seek educational experiences for themselves.

Other professionals within the practice including other GPs, nurses, managers and allied health professionals may also deliver IPT in addition to, or on-behalf of, the supervisor, but this does not negate the responsibility of the supervisor as the primary contact in this process. Other learning experiences such as corridor teaching are a vital part of the entirety of the practice-based learning experience. The role of learner and teacher in this exchange is an important skill to gain during training, as this style of interaction best represents ongoing practice based learning and teaching over the course of the GP’s professional life. Corridor teaching, however, does not constitute a suitable format for the entirety of the formal requirements for IPT.

3

Definitions

Training advisor: A medical educator acting as an adviser or mentor to a registrar during their training term(s).

Supervisor: A general practitioner accredited to supervise general practice registrars. A supervisor has the responsibility of guiding a general practice registrar during their training, and providing them with clinical education, management and supervision. The term ‘trainer’ is also used in some RACGP documents, sometimes interchangeably and sometimes to denote a delegate of the supervisor.

Medical educator: A general practitioner who provides, designs and participates in quality education, training and support.

Regional training provider: A regional training provider (RTP) is an organisation created to deliver education and training within a specific geographical region.

Training post: A general practice, hospital, Aboriginal Community Controlled Health Service (ACCHS), or other health service accredited for general practice registrar training and/or placement.

General practice registrar: A registered medical practitioner enrolled in the AGPT program and undertaking their training towards fellowship of the RACGP or ACRRM.

4

General practice trainer: A qualified vocationally registered general practitioner who is accredited to train general practice registrars in a clinical setting. They hold either a FRACGP or FACRRM, or equivalent. General practice trainers are responsible for clinical education and placement management, including the role of general practice supervisor and mentor.

What teaching should I receive?

Summary of in-practice teaching standards Both The Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) clearly prescribe the requirements for registrar IPT. The colleges also provide direction as to what content can be covered in teaching sessions.

RACGP The RACGP standards clearly define the IPT requirements for registrars studying towards this end. This summary is derived from the Companion for Standards for General Practice Education and Training: Trainers and Training Posts 2005 (version 2) pp. 7–16.

The trainer must be available for teaching, support and discussion for three hours per week for the registrar’s first six months of general practice training, and 1.5 hours per week for the second six months. In term 3 (GPT3) of general practice training, onehour of structured learning time per week is required.

GPT1 and GPT2 registrar placements include a minimum one-hour of protected teaching time per week. This means that the trainer must provide a one-hour block of uninterrupted face-to-face teaching to the general practice registrar every week.

The length of protected teaching time for registrars undertaking part-time training must be negotiated and agreed to by the medical educator, trainer and registrar, but cannot be less than 30 minutes per week.

Protected teaching must occur in an interruption-free environment (with the exception of emergencies). For example, it is not satisfactory to hold protected teaching sessions in the staff lunchroom with other staff members present.

For GPT3 registrars, the one-hour of structured learning time per week may be undertaken in a variety of ways, provided that the strategy employed meets the registrar’s learning needs and it is agreed to by the medical educator and trainer.

Table 1 – Details of teaching and/or learning time per week by term First six months of general practice training (GPT1)

Second six months of general practice training (GPT2)

Final six months of general practice training (GPT3)

In-practice teaching time

1 hour

1 hour

N/A

Other teaching time

2 hours

0.5 hour

N/A

Other structured learning time

N/A

N/A

1 hour

Total (teaching/structured learning) time

3 hours

1.5 hours

1 hour*

5

continued …

The trainer must provide a planned education session each week in the one-hour face-toface session. These sessions must be consistent with the registrar’s learning plan, and at an appropriate level considering the registrar’s knowledge and experience. The registrar may prepare the sessions.

ACRRM The standards for IPT for registrars on the ACRRM program can be found under the Primary Rural and Remote Training Standards for Supervisors and Teaching Posts, which is available at acrrm.org.au/teaching-posts AGPT program registrar on the Vocational Preparation Pathway Supervisors are required to provide structured educational activities: • PRRT1: 3 hours per week (first six months) • PRRT2: 1.5 hours per week (second six months) • thereafter: according to the registrar’s needs.

Registrar with the Remote Vocational Training Scheme (RVTS) Supervisors are required to maintain regular contact: • first six months: one-hour per week • second six months: one-hour per fortnight • thereafter: one-hour per month.

6

Additionally, supervisors should: • participate twice yearly in a three-way teleconference between the registrar, supervisor and an RVTS medical educator • visit the registrar once per year as a part of a clinical teaching visit • join weekly tele-tutorials in which their registrar is presenting a case (twice per year).

Content As a general practice trainee, you have three main learning environments: • the practice • RTP based education release, and • individual study.

In the practice, you will learn through seeing patients, and from the experienced professionals delivering your teaching. During your time as a registrar, you will use all three environments to cover the colleges’ curricula, pass your exams, and gain other important skills and knowledge required for being a successful, caring GP. You should consider the optimal environment to refine specific skills and knowledge. To maximise your learning it is vital to plan and be proactive.

continued ‌

There is great freedom as to what should be covered during IPT time sessions, and the content should match your learning needs.

You should consider the areas of expertise of the individuals delivering your teaching.

Some registrars have tutorial-style sessions on topics such as management of clinical conditions; some prefer to use these sessions to discuss difficult cases, and others prefer skills-based tutorials.

Other activities could include observing your supervisor or others in the practice, or having your supervisor observe you. Most registrars learn best from a mix of these activities. The colleges’ curricula (racgp.org.au/curriculum or acrrm.org.au/primary-curriculum) and BEACH data (sydney.edu.au/medicine/fmrc/beach) of common presentations in general practice can give you ideas for tutorial topics.

Just remember that for RACGP registrars, one hour per week during GPT1 and GPT2 must be face-to-face, uninterrupted teaching time, and that there is an additional two hours per week in GPT1 and a 0.5 hour per week during GPT2 for other activities such as case discussion and performance reviews.

For ACRRM registrars on the AGPT program, this protected education time is not clearly stated as face-to-face, but is implied.

7

How do I make the most of the teaching?

Once the time requirements for teaching have been satisfied, it is important to ensure you are getting the most out of your teaching time. Effective learning is not a passive process, and each registrar is responsible for his or her own learning as much as the supervisor is.

It is important to be an active and reflective learner. It can be helpful to know what type of learner you are, and what tools are available to help you plan and conduct your learning.

(See Table 1 and 2 opposite.)

Learning plans Learning plans are one of the most important and useful tools that you can use to direct your teaching and learning during general practice training. Many registrars do not fully realise their worth until later in their training after opportunity for their optimal use is lost. Right from the start of training, talk to your colleagues, senior registrars, your medical educator or training advisor, and your supervisor about developing the best learning plan style and type for you. If used well, learning plans are the best way to take control of your own learning.

8

It is important that you speak to your supervisor about your learning needs ahead of time and negotiate appointments for teaching.

Learning plans are a great way to assist this process. Some RTPs have electronic platforms to assist in the development of your learning plan: others prefer to use a paper-based system or a combination of both. The style and format of your learning plan will evolve over time, but should always be an integral part of your learning.

Here are some useful ways a learning plan can benefit your learning: • a reminder to reflect regularly on your personal learning needs • a communication tool with your supervisor and medical educator • a way to track your progress • a way to help visualise your areas of strength and weakness • a way to make sense of the different learning and teaching environments on offer • a way to plan your exam study.

Tips for more useful learning plans 1. Let your experiences guide your plans.

Your learning plan is more relevant when it relates to your day job. Try not to pick topics randomly as they enter your head.

Add learning goals to your plan based on the cases you have seen and perhaps struggled with.

2. Set a timeframe.

3. Be action oriented. Instead of ‘learn about menopause’, be specific in what you would actually do. For example, learn more about menopause by attending a sexual health and family planning workshop.

4. Know what steps you will take in your learning. For example, plan your first step with a particular topic. What will you do first? What resources will you use?

continued …

Table 1 Style

Description

Suitable activities

Activist

Enjoys novel experiences and problem solving. Becomes bored with long-term implementation. Happy to be thrown in the deep end with a difficult task

• Brainstorming • Group work and discussion • Role-playing, games

Reflector

Likes to stand back and ponder experiences. Collects data carefully and considers all options thoroughly before acting in a methodical way. Likes to have time to prepare

• Reflection • Activities where they can observe others first • Observing and discussing reflections with a close mentor • Journaling/note-taking

Theorist

Enjoys analysing and devising explanatory models. Likes structure.

Takes a logical and step-by-step approach. Perfectionistic and wants things to ‘make sense’. Feels uncomfortable with uncertainty and jumping to conclusions

• Lectures • Structured activities with a clear purpose • Reading books and articles • Likes to ask questions

Pragmatist

Prefers practical experiences. Likes concepts that can be applied to their job. Impatient with lengthy discussions and activities that are all theory. ‘Down to earth’

• Trial and error • Behaviour modelling • Demonstrations and copying a model example • Hands-on • Projects • Likes feedback and coaching

(Kolb 1984; Honey & Mumford 2006)

Table 2 Visual

Learns through watching. Prefers sitting at the front of a class to avoid visual obstructions. Likes pictures, diagrams, and videos. Needs slides and handouts

Auditory

Learns through listening. Enjoys discussions and lectures. Remembers what people say. Written information may have little meaning unless someone explains it

Kinaesthetic

Learns through doing. Likes a hands-on approach. Finds it difficult to sit still for long periods. Needs to actively explore. Enjoys experimentation

(Fleming 1992)

9

continued …

5. Know why you have added that goal.

When you add a goal to your plan, make a note of why you have added it, and how useful it will be to you in your practice when you achieve your goal.

6. Keep it simple. Make your goals specific and achievable within a limited time frame.

7. Be creative. Have you considered videotaping consultations, role-playing situations with your supervisor, plotting a case or consult with a particular framework or consultation maps, or conducting group discussions with other registrars?

8. Test yourself. How will you know you have improved? Practise multiple choice questions (MCQs) or Objective Structured Clinical Exams (OSCEs), a case audit, talk it over with your supervisor, ask for patient feedback or attend a course and complete the assessment.

9. Keep updated. Make a note on your learning plan of what you have completed and achieved.

10. Review it frequently.

11. Adjust it to suit. For some learners, a complicated long-term learning plan may be demotivating and counterproductive.

Simple, small, and short-term goals may be more suitable. Others may prefer a detailed year-long plan covering all their learning needs. Try not to feel constrained to a single template. Work out what works best for you.

10

An example learning plan template: Goal – What do I want to achieve?

Why? – How did I know I needed to learn this?

Actions – What are the steps I will take?

When? – What is the timeframe for this goal?

How? – In what way will I know I have achieved my goal?

Learning styles Everyone has a different learning style, or more precisely, a different combination of various learning styles. Some are better at bookwork, whilst others prefer brainstorming discussions in groups. Some prefer careful thinking and planning while others like to jump in and be hands-on. Lectures work well for some, interactive demonstrations work better for others. As a registrar, you might be someone who writes notes or finds diagrams and mind maps more helpful. If you are not sure what type of learner you are, there are quizzes that you can take to find out. It is worth discussing your learning style, and how this matches (or not) with your supervisor’s own teaching and learning style. Every individual will have traits from various learning styles.

There are also additional academic models of learning styles. Recognising your own learning style or traits and the learning activities that suit your learning styles will help you best negotiate IPT with your supervisor. Identifying your supervisor’s learning style may help explain why the teaching you are receiving may seem ineffective, and prompt discussion

continued …

with your supervisor on how to improve your learning experience.

What is the difference between teaching and supervision?

What can I do if my supervisor’s style does not match mine?

The terms ‘teaching’ and ‘supervision’ are often used interchangeably in general practice training, but they are not interchangeable.

It is important that you and your supervisor understand the difference. It must be emphasised that the one-hour protected face-to-face component in GPT1 and GPT2 for RACGP registrars must be used for teaching, and not supervision.

Teaching time can become a source of frustration when the styles of supervisors and registrars are different. Supervisors do not want to give teaching that does not benefit the registrar, but they may be quite ingrained in their own teaching and learning style. Perhaps it does not cross their mind to attempt a different approach.

Here are some ways a registrar might adapt: • suggest to your supervisor they may use some of your teaching time to conduct activities that you find useful, eg. to observe you while you perform a procedure, review a videotape of your consult, role-play a case you struggled with or review your medical records • ask if some of your teaching time can be used in learning experiences that may not involve your supervisor, eg. assisting a surgeon in operation, doing an audit, sitting in with another senior GP at the practice, completing a computer based learning activity (eg. gplearning) • take the lead in teaching time, eg. you present a case and a topic to your supervisor for feedback and to stimulate discussion.

Supervision To supervise (verb): 1. To direct or oversee the performance or operation of … 2.

To watch over so as to maintain order, etc (dictionary.com).

Kilminster et al. (2000) define supervision as the provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainee’s experience in providing safe and appropriate patient care.

This definition recognises that some benefit can be derived from analysis of errors, their management, and resultant lessons learned.

The anticipatory element of supervision is necessary to isolate and deal with threats to patient safety. The ‘personal’ issue in the definition is an attempt to acknowledge that many problems with competence can arise from personality-related variables, and that these are often the most difficult aspect to deal with for the supervisor and trainee (Kilminster et al. 2007).

11

continued ‌

There appears to be general agreement that the essential aspects of supervision are that it should ensure patient/client safety and promote professional development. Clearly, there may be occasions when these two aspects are in opposition. There is also agreement in the general literature that supervision has three functions: educative, supportive and managerial/ administrative. In the context of medicine, this would include guiding patient management (Kilminster et al. 2007).

Kilminster et al. further note that supervision should include clinical management, teaching and research, management and administration, pastoral care, interpersonal skills, personal development and reflection. Furthermore, it is also suggested that the student-supervisor relationship is partly influenced by the supervisor’s commitment to teaching as well as the attitudes and the commitment of both the supervisor and trainee.

Teaching Teach (verb): To impart knowledge of or skill in; give instruction in (dictionary.com).

12

Teaching in the clinical environment is defined as teaching and learning focused on, and usually directly involving, patients and their problems. Skills such as history-taking, physical examination, patient communication and professionalism are best learnt in the clinical setting. Medical knowledge is directly applied to patient care. Trainees can begin to be motivated by relevance, and self-directed learning takes on a new meaning (Spencer 2003).

Teaching in the clinical setting often takes place during the course of routine clinical care where discussion and decision-making take place in real time. Often this teaching will centre on an analysis of actual patient care that has been previously undertaken. Learners can benefit from additional sessions specifically planned for teaching. These sessions may take place in the ordinary clinical environment and make use of the patients who are opportunistically available. Alternatively, they may be highly structured sessions with particular patients recruited especially for the session (Ramani & Leinster 2008).

Due to advances in education, including new methods of teaching and learning, more student-centred teaching, competency based assessment, and emphasis on professionalism, educators today are required to have an expanded toolkit of teaching skills and clinical expertise (Harden & Crosby 2000).

Although teaching during consultations is organisationally appealing and minimally disruptive, it is limited in what it can achieve if students remain passive observers. One limitation may be that the teacher does not see the student in action. Teaching during consultations also inevitably slows the clinic down, although not as much as might be expected. In an ideal world, it would always be sensible to reserve clinical time to accommodate teaching (Spencer 2003).

YES

Am I getting my in-practice teaching as per the RACGP or ACRRM standards?

Congratulations!

Are you making the best use of this time?

Troubleshooting NO

.

So what do you do next?

Practice

Try talking to your supervisor Get the practice manager to schedule it in the appointment book first thing in the morning so no-one is running late Make sure your teaching time is a point is clearly defined in your employment contract

If that doesn’t work

RTP

Speak with your director of training, medical educator or registrar liaison officer

If that doesn’t work

GPRA

1300 131 198 enquiries.org.au

GPET

GM Education and Training

References Australian College of Rural and Remote Medicine. Standards for supervisors and teaching posts. Brisbane, Queensland, 2011. Available at www.acrrm.org.au/files/uploads/pdf/vocational training/CCT standards_1.pdf.

Fleming ND, Mills C. Not another inventory, rather a catalyst for reflection. To Improve the Academy 1992;11:137. Available at www. vark-learn.com/documents/not_another_inventory.pdf.

Harden RM, Crosby JR. AMEE Guide No. 20: The good teacher is more than a lecturer: the twelve roles of the teacher. Med Teach 2000;22:334–47.

Honey P, Mumford A. The Learning Styles Questionnaire, 80-item version. Maidenhead, UK: Peter Honey Publications, 2006.

Kilminster SM, Jolly B, Grant J, Cottrell D. Good supervision: Guiding the clinical educator of the 21st century. Sheffield: University of Sheffield, 2000.

RACGP/ACRRM GM Education and Training

Kilminster S, Cottrell D, Grant J, Jolly B. AMEE Guide No. 27: Effective educational and clinical supervision. Med Teach 2007; 29:2–19.

Kolb D. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall, 1984.

Ramani S, Leinster S. AMEE Guide No. 34: Teaching in the clinical environment. Med Teach 2008;30:347–64.

The Royal Australian College of General Practitioners. Companion for Standards for General Practice Education and Training: Trainers and Training Posts (Version 2). 2005. Melbourne, Victoria: pp 7–16.

Available at www.racgp.org.au/education/rtp/general-practicevocational-training-standards/2005vts/.

Spencer J. Learning and teaching in the clinical environment.

BMJ 2003;326:591–4.

13

The future of general practice

General Practice Registrars Australia Ltd Level 4, 517 Flinders Lane, Melbourne Victoria 3001 P 03 9629 8878 W gpra.org.au