Grouping Registrars in Practice Placements

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Grouping Registrars in Practice Placements

• How many can one trainer supervise?

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Literature Review

• One to one evolved out of circumstances in GP in
  early 70s
• Successful but why?
• One to one or due to development of a skilled
  workforce of doctors trained in educational
  methods and the supernumerary status of GP
  registrars which allowed for protected time for
  teaching.

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Identified problems

• Stress of assessments
• Family / Job conflict
• Unprepared for independent practice
• Lack of protected time for teaching reported
  less in later surveys
• Social isolation lack of peer support
• Lack of feedback

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Question

• What is the impact of
• a trainer supervising more than one registrar?
• grouping registrars in practice placements?

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Method

• Two phase
• Questionnaire practice managers how practices
  manage registrars
• Semi-structured interviews practice managers,
  GP registrars in second practice placement , GP
  trainers supervising more than one registrar,
  Scheme Organisers
• Ethics approval obtained
• Data analysed for themes.

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Results

• 3 of 6 schemes had 2 registrars placed with one
  trainer. 3 SO interviewed
• 11 trainers working in 9 practices - 9 were
  interviewed
• 8 registrars 7 agreed to be interviewed.
• Questionnaire 62 response rate.
• Practice managers 4 interviewed

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Trainers

• 3-16 years as a trainer
• Practices 3,000 14,000 patients
• Some supervising one FT reg and one PT or ITP
• 3 were supervising 2 FT registrars
• 5 of 11 Course organisers or ex COs

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Registrars

• 7 interviewed, all with prior experience of one
  to one training relationship
• All had experience of joint tutorials, 5 had
  experience of joint debriefs
• Trainers were supervising up to three mostly a
  combination of full time and part time.

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Differences between practices training more than
one doctor
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Trainers why involvement

• New, interesting and challenging
• Professional development
• Had been asked
• Inspired by a course
• All practices had received funding for extra rooms

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Trainers benefits

• Enjoyable, challenging, interesting
• Developed as an educator 6
• Enjoyable watching the registrars interact
• Altered structure of the day more time for
  teaching less seeing patients easier to
  prioritise teaching time 80/20 to 50/50
• Three easier than two

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Trainers - costs

• Stressful but generally positive S.O.s worried
  about burnout
• Less available for patients
• Partners how many patients did you see today?
• Need to be well organised
• Need for flexibility
• Balancing needs like a family

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Practices - benefits

• Positive effect on atmosphere
• Improve the practices understanding of training
• Enhance the learning environment Are up to date
  and model a learning group
• Easier for registrars to contribute to meetings
• Increase in availability of appointments
• Positive effects on patients

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Practices - costs

• Complex organisationally timetabling PT, FT,
  ITPs / room allocation
• Induction fatigue
• Cant be treated as supernumerary with holidays
  in a small practice particularly

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Registrars - benefits

• Less isolated socially and professionally
• Decreased intensity of trainer registrar
  relationship less dependency and collusion
• Opportunity for teaching
• Easier to prepare for tutorials
• Greater depth in tutorials ethical issues
• More challenge of trainers views

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Registrar Benefits - contd

• Learn about functioning as a group
• More independence feedback to the practice
  easier
• Relate to more than one trainer

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Registrar - costs

• Less individual time
• Feedback given poorly by another registrar
• Issues over sharing rooms tidiness etc
• Difference in quality of 360 degree feedback
• Personality clashes
• Registrars with difficulties
• One registrar concern about disruption to
  teaching caused by a practice move.

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Educational effects

• Comparing progress
• Develop skills of an independent learner
• Issues about differences in learning needs not
  often
• Recognising hidden learning needs
• Deeper and more thorough learning in joint
  training

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Specific activities

• Video second opinion, feedback very good for
  MRCGP, 5 submitted video all passed 2 with merit
• Joint debriefing positive can see how peers
  perform, learn from others mistakes but can be
  lengthy
• Joint tutorials More relaxed, less intense,
  trainers need group facilitation skills

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Peer contact

• Sharing knowledge and experience
• Learn the obvious from each other
• Easier to ask a peer
• Bounce ideas off each other
• More fun
• Social contact
• Observed talking the talk!

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Scheme Organisers concerns

• High level of organisation at practice and scheme
  level
• Importance of equity between practices
• Lack of clarity about who the trainer is
• A stressed practice
• ?should be additional criteria
• Will all these registrars have jobs?

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Conclusions

• Some trainers are prepared to work in this way
  developing skills as an educationalist within the
  practice 17 of trainers delivering 30 of
  capacity
• Registrars value peer contact
• Practice environment enhanced
• Need to maintain some one to one
• Flexibility required to deal with individual
  needs
• Need to loose the concept of registrar being
  supernumerary

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And finally

• My experience here has been that the informal
  discussions have almost been as good as the
  formal tutorials. I have felt better for it.
  I have gained more from it from a personal
  openness point of view talking to the other
  registrar. And I preferred it that way, than
  being here on my own as an only registrar, with
  the benefits of having more one-to-one. It's
  more enjoyable having another registrar here.

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Action Points - The training programme

• Adequate time for a balance of one to one and
  joint activities in the week.
• Debriefing should not be solely a joint activity
• There needs to be flexibility in the training
  timetable to enable changes to be made according
  to the needs of individuals
• Timetabling should ensure that the registrars
  have opportunity for informal contact in a normal
  working day

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Action Points the practice

• The whole practice needs to be committed to
  training.
• The practice needs to provide a high standard of
  organisation and clarity for the registrars about
  supervisory arrangements.

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Action Points - Registrars

• Registrars need to take responsibility for most
  of the record keeping
• Educational processes and skills e.g. the giving
  of effective feedback should be discussed at the
  start of each attachment.
• Should be encouraged to contribute to practice
  activities

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Action Points trainer development

• Trainers should be asked to submit videos of
  joint training activities as part of the trainer
  re-approval process
• Trainers to be offered the opportunity to develop
  their group skills