Multi-level learning also requires different methods and approaches to teaching and supervision, and engagement of a team of teachers, doctors, nurses and other practice staff. Engagement and cooperation of patients is central to success as well.

Diagram 1 provides a pictorial summary of the essential elements of an ML (vertically integrated) teaching practice.

The learning culture

Some overarching characteristics of successful teaching practices with different levels of learners have been identified. There is evidence that the learning culture in a practice impacts on the learners, so it is important to give some thought to this aspect of an ML teaching practice.

These are some of the elements of a practice identified by supervisors that appear to enhance the learning culture for medical students, GP registrars and experienced GPs alike. These elements are:

• an enjoyment of teaching and learning by all members of the practice;

• a teaching ethos, and a commitment by the practice; and

• flexibility in teaching arrangements in the practice.

Enjoyment of teaching and learning

Perhaps the most important ingredient in a successful VI practice is the enjoyment of learning. Enjoyment of learning by GP supervisors sets an example for all other members of the practice, and supervisors are important role models to all learners. For GP supervisors, enjoyment of teaching is important in motivating them to teach and in sustaining the learning environment. Enjoyment of teaching also prevents burn-out and teacher fatigue.

Supervisors enjoy the interaction with younger colleagues and appreciate seeing learners grow in knowledge and competence under the supervisor’s tutelage. Supervisors usually enjoy the challenge of teaching and being questioned, and often relish the opportunity to promote general practice as an interesting and worthwhile medical career. Supervisors also find that teaching is an enjoyable form of continuing professional development that keeps them up-to-date clinically.

Junior learners enjoy having ready access to experienced clinicians who are committed to teaching. The opportunity for interaction with a small group of near-peer learners in a VI practice is appreciated by junior learners, as is interaction with other practice staff members who are committed to their learning.

Teaching ethos and commitment

Multi-level practices identify teaching as a core component of their business. These practices recognise that teaching commitment contributes to the overall quality of both the practice and the clinical care provided to patients. Some teaching practices express the ethos and commitment in a business plan that clearly articulates their teaching commitment and the way it will be planned and funded.

There is a range of ways that practices can express their ethos and commitment to teaching. Many practices involve all their practice staff in teaching meetings. However, various members of the practice team require clearly identified teaching roles to ensure that the commitment to teaching is materialised. For example, the role of supervisors needs to be clearly identified, and other teaching roles (for example, the GP registrar, practice nurses and practice administration staff) need to be established and defined. Some practices use patient newsletters, information sheets, signs and posters as a mechanism to demonstrate the practice commitment to teaching and learning, and as a way to engage patients in the endeavour.

Flexibility in teaching arrangements

One of the major challenges of VI practices is coping with the learning needs of learners at different levels and stages of experience. Most ML practices have adapted or changed their teaching models to suit the different levels of learner in the practice. Changed teaching practices are driven partly by the varying needs of the learners at any given time, partly by the capacity of the practice staff and partly by seeing what works through a process of trial and error. It is essential to be flexible and keep changing and evaluating teaching methods. Some practices undertake formal annual evaluation of their teaching at a meeting of the teaching team.

Learners have reported that GP supervisors in VI practices are particularly responsive to their needs, flexible regarding the type of learning opportunities being provided, and able to deliver teaching in innovative ways.

The planning and organisation of learning

Effective learning needs planning and organisation. Many VI practices will document their learning arrangements in a practice teaching or learning plan so that all participants are clear on the opportunities available.

The most important element in any teaching practice is its team of teachers. It is the committed supervisors and other teachers that ensure learning occurs in the practice.

Other organisational factors, including teaching administration, space in the practice for group teaching and the learners’ consultation room/s, patient bookings and financial arrangements, are all important in creating an environment for effective learning.

Teaching team

Increasing the number and skills of teachers within a practice has become an important capacity issue. A nominated single or group of GP supervisors, usually practice principals and experienced GPs, has traditionally undertaken teaching in general practice. More recently, teams of teachers are developing in practices. These teams may include GPs, GP registrars, practice nurses, practice managers and other allied health professionals.

GP registrars are more often adopting teaching roles as a part of their general practice training. It is now recognised that near-peer teaching has many advantages. This is one of the key innovations in an ML teaching practice.

Medical students are also being viewed as teachers as well as learners in some circumstances, as the concept of ML learning and teaching evolves.

Administration

Most VI teaching practices have a dedicated staff member who is responsible for the organisation of teaching activities in the practice. This might include liaising with various education organisations about arrangements for learner placements, addressing accreditation requirements, and administering teaching payments. Internally, this person may also organise timetables and programs for group and individual teaching sessions, supervision allocation and patient flow for each clinical session.

Space

Setting aside dedicated consulting space for both medical students and GP registrars is essential for hands-on learning. A dedicated consulting room enables the learner to see patients independently, which promotes autonomy in clinical decision making and patient care. Many teaching practices have increased their physical size to accommodate an expanding teaching commitment and an increasing number of learners in the practice.

A sufficiently sized room is also essential to accommodate larger gatherings of learners for group tutorials or meetings. It is preferable for such a room to have easy access to audiovisual learning aids.

Patient arrangements

Patient booking in teaching practices needs to be planned and managed. Consideration should be given to ensuring both students and registrars are seeing appropriate patients at the right pace, with clearly documented arrangements and responsibilities for supervision. Organising patient bookings also involves careful planning and co-ordination of supervisor and learner patient flow. This becomes even more critical if the practice has implemented a parallel consulting model of supervision.

Financial arrangements

Practice managers are essential in organising the necessary paperwork and claims for remuneration from the various organisations that fund teaching in the practice.

Some supervisors have said that integrated learning models improved the financial viability of teaching in the practice. Other GP supervisors have indicated they have reduced earnings from consultations when they take on a teaching load; however, they usually indicate that they receive personal and professional benefits from teaching.

Teaching methods

There are numerous very specific models and arrangements for learning and teaching that appear to work well in an ML learner context. Examples of these methods include regular ML group tutorials and case discussions, planned informal teaching and exchanges, encouraging patients to contribute to teaching and interdisciplinary teaching sessions.

It is still important to maintain some focus on individual learning needs with some dedicated individual teaching time and direct observation of the individual learner.

Multi-level group tutorials and case discussions

Regularly scheduled tutorials (usually weekly) appear to be the most common form of ML learning in general practice. Participants usually include all three levels of learner: GP supervisor, GP registrar and medical student. In most cases, all participants are given the opportunity to present topics or cases and to lead discussions. In some practices, practice nurses and allied health professionals are also involved in teaching meetings. Decisions about other learning activities and opportunities in the practice are often made at regularly scheduled teaching meetings.

Informal teaching and learning

Medical students, junior doctors, GP registrars and GP supervisors have all identified informal learning as making a significant contribution to the learning experience in a general practice.

Informal learning—learning that has not been formally structured—is seen by participants as having a key role in learning about specific patient care, particularly as all levels of learners observe or discuss patient care. ‘Tea room exchanges’ and ‘corridor consultations’ are examples of informal contact that both supervisors and learners recognise as learning opportunities. Informal exchange between individuals with differing levels of experience appears to be both important and valuable. Informal discussions often contribute to learning about general medical issues, as well as being an opportunity for mentoring and career planning. Informal learning also takes place during interdisciplinary interactions, particularly with practice nurses.

Patients as teachers

It has been a long tradition that teaching within the clinical context with ‘real’ patients is essential to medical education. Patients are generally satisfied with participation in student learning. However, a small number of individuals, particularly those being managed for mental health conditions, may find a student’s presence distressing. It is important to remember that each consultation with a medical student and a GP registrar is also a learning interaction with the patient, in which the patient contributes to that learning. The patient as a teacher is more actively recognised in many ML practices, and it is not uncommon for a teaching practice to have a pool of patients on whom they call for specific learning opportunities.

The patient may also take a more formal role, contributing to aspects of the teaching program such as assessment, curriculum development and workshop delivery.

Interdisciplinary teaching

Practice nurses are a well-recognised part of the general practice teaching team in VI practices. Practice nurses are often involved in educating medical students and GP registrars in areas such as wound management, immunisation, practice standards and chronic disease management.

Larger practices may also have allied health professionals as part of the health care delivery team. Currently, the direct involvement in GP education of allied health professionals may be limited. However, this role is increasing both within the practice through participation in group tutorials, and outside the practice through visits to other clinical work sites (for example, pharmacies).

Individual teaching

Maintaining regular opportunities for individual teaching of the learner in an ML practice is important and cannot be replaced by purely group learning activities. GP registrars and medical students still require individual one-on-one time with their designated supervisor. Often this will involve individual case discussions, but some of this time must also involve observing and giving feedback to the learner on their clinical interactions with patients.

Supervision

The role of GP supervisors in ML practices is expanding, and different models of supervision have been developing.

Parallel consulting

Parallel consulting (also known as ‘wave’ consulting) is a common form of supervision used in VI teaching practices. Parallel consulting consists of a GP supervisor consulting with patients in parallel with either a medical student or a junior doctor (or at times both). Many GP supervisors find parallel consulting is a time-efficient model of supervision, providing the capacity to supervise several learners concurrently. Learners also appreciate the safe, supervised autonomy in clinical experience that parallel consulting offers.

Leading the teaching and supervisor team

In the VI practice, GP supervisors, and particularly the designated principal supervisor(s), will have the additional role of leading the teaching and supervisors. Team leadership involves training other teachers and acting as a role model and mentor, for both the clinical and teaching roles. Taking responsibility as the lead supervisor is an additional role that takes time and effort, and this needs to be recognised and appreciated within the practice.

Supernumerary GP supervisors

Engaging supernumerary GP supervisors is a teaching model that is evolving in ML teaching general practices. In some ways this model mirrors the role of the consultant in a specialist clinic outpatient session, in which a designated consultant takes responsibility for supervision of learners for a specific clinical session. A supernumerary GP supervisor takes oversight of all the registrars, junior doctors and medical students working in the clinic during a session, often without his or her own patient load.

GP registrars as teachers

GP registrars are increasingly engaging in a teaching role in general practice, particularly as teaching is now formally recognised as a core skill of general practice and is included in the curricula of both Colleges. The benefits of near-peer teaching are well documented. Registrars acknowledge that teaching assists their own learning and provides an opportunity to contribute back to the teaching practice. It is important to give GP registrars the opportunity to teach, and to provide them with support and training while undertaking their teaching roles.

Read more about GP registrars as teachers.

General Practice Supervisors Australia. Vertical and Horizontal Learning Integration in General

Practice. General Practice Supervisors Australia, 2016. http://gpsupervisorsaustralia.org.au/guides/

(accessed March 2017).

• This is a guide to VI learning, developed by experienced supervisors. It provides case studies and

  risks and benefits of this form of teaching.

Dick M-L B, King DB, Mitchell GK, Kelly GD, Buckley JF & Garside SJ. Vertical Integration in Teaching

and Learning (VITAL): an approach to medical education in general practice. Med J Aust 2007;

187(2):133–135.

• This is one of the first journal articles describing VI. The article provides a framework for

  approaching VI, and lists advantages and barriers to VI as gleaned from research conducted with

  GP supervisors, GP registrars and medical students.

Thomson JS, Anderson KA, Mara PR & Stevenson AD. Supervision—growing and building a

sustainable general practice supervisor system. Med J Aust 2011; 194(11):S101–S104.

• This article summarises challenges for practices. The article suggests approaches and solutions

  to supervision as numbers of learners in the practice increase.

General Practice Education and Training (GPET). A Framework for Vertical Integration in GP

Education and Training. Canberra: GPET, 2004.

• This is an original VI education framework.

Thomson JS, Anderson K, Haesler E, Barnard A & Glasgow N. The learner’s perspective in GP teaching

practices with multi-level learners: a qualitative study. BMC Med Educ 2014; 14:55. http://www.biomedcentral.com/1472-6920/14/55 (accessed March 2017)

• This article present findings from qualitative research on the benefits and limitations of various

  multi-level learning teaching methods. The article provides some insight into methods of teaching,

  as well as characteristics of teachers and the practice that enhance learning opportunities.

References for Essential Elements of a Multi-Level Teaching Practice