On this page:

Foreword

Background

Purpose of this guide

Vertical integration

An introductory story

Definitions

Suggested further reading

Professor Nicholas Glasgow

BHB; MBChB(Auckland); GradDipFamMed(Monash); GradCertEdStudies(Sydney); MD(Auckland); MD (honoris causa International Medical University Malaysia); FRNZCGP(Dist); FRACGP; FAChPM

Some 38 years ago I was a medical student, in my early 20s, and on my way to my first clinical placement with a general practitioner (GP). We students had had some preparatory tutorials and orientation from the medical school’s general practice and community health faculty before the placement, but much of this seemed to me at the time to be rather distant from patient care. The tutorials seemed to have more to do with things like prevention or funding health systems, and I didn’t give these sessions the attention they deserved. After all, I knew about GPs—I had one of my own (even if my own interactions were infrequent). He was our family’s GP and I knew of some of his interactions with other family members. Most importantly, I knew that he was held in very high regard by my parents, and when conversations about this GP arose in our home, the consistent theme was the excellence of his care. In addition, because my father was a medical specialist, I had some understanding of the role GPs play in making referrals.

So, with that superficial knowledge of general practice I arrived at a solo practice in a busy part of a blue-collar suburb, where I was warmly greeted by the receptionist and the GP, and made to feel at home. I was to be there for two weeks and (with appropriate patient consent) during that time I was to sit in on clinic consultations, go on home visits and attend any deliveries with the GP. I wasn’t clear about what exactly the objectives for this immersion experience were—a sort of vague notion of imbibing the essence of general practice perhaps, not dissimilar to the way clinical placements with other specialties worked at the time. I sat in the consulting room and observed. The practice was very busy. I found it difficult to follow what was going on. The GP seemed to know much more about the patients than the usually brief and focused history and examination conveyed to me, even allowing for my inexperience. Decisions were made, sometimes tests were ordered, usually a prescription was written, and the consultation would finish. Before I had really processed what had happened or why, the next consultation began. And the next one followed. And so on. Thirty to 40 patients a day, five days each week for the two weeks. At lunchtime, driving to a home visit, or again at the end of the day, the GP would chat about anything I wanted to know regarding the patients that had been seen. He was genuinely open to talking, always willing to share his wisdom, and motivated to help. But the problem was the series of consultations were mostly a blur, and on top of that, I didn’t really have any clue about what was going on in most cases as they played out in real time. To compound the problem, my own pride meant I didn’t want to look a fool by asking what might turn out to be a silly question. At the end of two weeks I knew two things:

1) the GP was a terrific person, warm and friendly and highly regarded by his patients; and

2) I didn’t understand what had gone on for most of the two weeks, and I didn’t understand why anyone would want to do that job—certainly not me!

As far as being a GP goes, I subsequently changed my views, and regard my varied career in general practice as being nothing short of a privilege. Perhaps if this book had been written when I was a medical student, I would have been a better prepared learner, the practice would have been a better prepared teaching practice, and I would have come to that view much earlier!

Associate Professor Jennifer Thomson and Associate Professor Katrina Anderson are very experienced GPs and internationally renowned medical educators. They have taught medical students, junior doctors and registrars, and have run continuing professional development activities for practising doctors. Their passion to continually improve the quality of medical education is clear to all who meet them. They are regularly sought out for their educational expertise and insights. Drawing on their years of experience as clinicians and educators, they have written this wonderful resource for anyone wanting to develop their teaching expertise.

The book is orientated around the realities of Australian general practice, and is of particular help to those working in that sector. But that orientation should not deter people working in other health settings from adding this book to their educational resources. The book is full of grounded and practical educational examples, advice, and tips that have proven to be effective in time-pressured clinical environments. It is relevant to anyone seeking to continuously improve educational activities in such contexts.

I found the book to be very accessible. The chapters are sensibly structured around important current topics. This facilitates the ease with which I could return to a tip, table or other prompt quickly to refresh my memory just before beginning a teaching session. The writing style is warm and engaging, and the text clearly displays the depth of experience the authors have. No ivory tower academic treatise this! A busy clinician could easily pick up a copy, quickly find some helpful information and practically apply it with ease.

This is a terrific addition to the medical educational literature. It is a credit to the authors and will be of great value to educators in Australia and beyond. I commend it to you.

General practice is a rich learning environment for medical students and doctors, as well as other allied health professionals, but crucial to the heart of this learning experience is the patient and their family.

The number of learners in general practices in Australia has increased over recent years and this has placed an increased demand on general practices to be engaged in teaching. There are now medical students, GP registrars, occasionally junior doctors, as well as supervised overseas trained doctors, all at varying stages of training in many general practices across Australia. This has demanded some new approaches to teaching and learning in the general practice context.

Most of the learning in general practice takes place in the clinical context of looking after patients within a small, private business model. Putting patients’ needs first while juggling teaching, managing a business and building a high-quality team of professionals is the daily challenge of many highly skilled GP supervisors. These individuals must be not only competent and compassionate doctors, but also skilled educators, leaders, mediators and mentors. GP supervisors need to create a collegiate learning and teaching environment in general practice to successfully train the next generation of doctors, while enhancing quality and care for their patients. If done well, patients and learners all benefit from a general practice community of learning.

The purpose of this guide is to assist GP supervisors to create a community of learning within their own practices. This guide is not intended to be a comprehensive discussion on GP supervision, although at times the guide covers some basic components to assist engagement in ML learning. Teaching and supervision can be very onerous, and we hope this guide presents concepts and ideas to enhance VI, while making it both practical and feasible. The guide is intended to be a practical resource for GP supervisors and any members of a teaching team in a vertically integrated GP teaching practice.

The authors both have had long careers in the GP education and training sector within postgraduate Colleges, vocational training, prevocational training and universities. They are experienced researchers in this area, with findings published in the literature. Some of those findings have informed the structure and issues presented throughout this guide.

Because VI is a relatively new phenomenon, there is little research and evaluation of what is happening in vertically integrated teaching practices. Limited peer-reviewed literature is available. However, this guide draws together the main themes of VI that are emerging from research. It also provides some detailed description and suggestions for application in general practice settings that are based on the literature and observations of current practice.

The guide contains many practical tips and tools for creating a vertically integrated community of learning in general practice. The practical tips have either been developed by the authors or have been observed by them in use in committed and innovative teaching practices.

This guide is designed to be a useful manual for GP supervisors and so we have identified at the end of each page a few specific references that may be worthwhile as further reading. We want the guide to be readable, practical and accessible for GP supervisors and practice staff and so we have put a full list of academic references on the Resources page, organised under section headings.

John Smith first encountered the world of general practice when he was a third-year medical student and placed in a general practice for six weeks. He was attached to a 55-year-old general practitioner(GP) supervisor, Dr White, who had been a GP for 20 years. The practice was busy, with three doctors, a full waiting room all day every day, and a practice nurse. John sat in with Dr White every day and watched him consult. Dr White would sometimes discuss an unusual patient presentation after the patient had left the room and occasionally he would ask John a question, but most of the day John sat in the corner and observed passively. Sometimes it was quite warm in the corner and John struggled to keep his eyes open. Each day he went home feeling tired and slightly bored, saying to himself “I would never want to be a GP”. John graduated with honours from his university and started his next stage of training.

When John was a junior doctor he was given a mix of hospital terms and a GP term as part of a general junior doctor year. His first rotation was a really interesting infectious diseases term. The ward rounds had been fascinating where the consultant, registrar, he and two medical students reviewed patients together every day. He learned so much because the consultant was really keen on teaching, so the discussion on rounds was always interesting. After the ward-round the students accompanied John to help him with all the tasks arising from rounds. He really enjoyed teaching the medical students skills and having them assist him. He was not looking forward to his general practice rotation, as he remembered how boring and lonely it was when he was a student.

John arrived at a fairly large general practice on the Monday morning and was welcomed by the practice manager and his allocated supervisor, Dr Tran. He was orientated to the practice and was told that for the first few days he would sit in with Dr Tran, but by the end of the week he would have his own room and be seeing patients. He was given a timetable that showed his room allocation, and his supervising GP for that session—there were three main GP supervisors, including Dr Tran. John was also given a timetable for the practice meetings. Every second morning the doctors gathered for a 45-minute meeting before starting to see patients. One day they discussed difficult cases, another day they discussed a current clinical topic, another day one doctor presented some evidence on clinical management of a condition. Each week, the general practice also had a learning meeting that involved students, the junior doctor and two registrars in the practice to discuss consultation skills.

John was very surprised that when he sat in with Dr Tran, he was included in each consultation. In fact, Dr Tran often asked his opinion on the latest treatments. By the end of the week, John was seeing his own patients, but Dr Tran insisted he come in at the end of each consultation just to check he was on the right track. By week five, John had grown used to the different styles of his numerous supervisors, and they seemed happy with his progress. John was surprised to find general practice was actually quite difficult, and there was never a dull moment because he really had to consider a range of issues and apply his clinical knowledge for almost all presentations. After a few weeks, some patients were coming back specifically to see John, and were even asking for him when they rang up to book. By week six, Dr Tran asked John if he could have a medical student occasionally sit in on John’s consultations. Students sometimes asked John tricky questions, but he was surprised at how much he did know and how much help he could give the students. By week eight, John felt like a real doctor for the first time and was so excited by how much he had learned. When it came to week 10 and the completion of his rotation, John realised how much he would miss general practice.

Two years later, John returned to the same general practice as a registrar and eventually stayed on after his Fellowship.

Why did John choose general practice after his initial reaction?

We hope this guide will provide you with some of the answers!

Learner

In this guide we use the word ‘learner’ as a term that broadly covers all the different stages of learning within the medical training environment. A learner for our context is a medical student, a junior doctor in their prevocational training years, a GP registrar training vocationally in general practice, or an international medical graduate. Multi-level refers to having learners from a variety of these stages. Although fully qualified GPs are also learning all the time, throughout this guide we refer to them collectively as supervisors.

Supervision and teaching

Clinical supervision has a broad definition and means different things in different contexts. In this guide we use the term in a number of ways.

Clinical supervision refers to a more experienced GP overseeing a clinical encounter of a more junior colleague. Normally the patient is at the centre of this encounter, although not necessarily present.

Principal supervisor refers to the person who has been allocated by an organisation to be the person responsible for the learner for the duration of their time in the practice. The principal supervisor normally completes the learner’s final assessment.

Supervisor is also used to refer to the person who is ultimately responsible for the care of the patient.

Clinical supervisor refers to the person who monitors, observes, co-consults or follows up encounters of direct patient care. A broader definition of supervisor, which we also use, encompasses any teaching sessions where one is discussing, advising or educating about the specific care of a patient(that is, the patient is at the heart of the discussion). GP supervisor generally refers to the person with overall supervision responsibility of a learner.

In medicine, if the teaching and learning is about disease and medical knowledge (for example, a tutorial on asthma) then the interaction with the learner is not considered to be ‘clinical supervision’. However, if part of the tutorial involves discussing a real patient case, then the interaction becomes part of clinical supervision. Therefore, we propose that in an ML teaching practice in which the curriculum is present in the patients who walk through the door, most of the teaching and learning taking place constitutes clinical supervision. Ultimately, good supervision is about empowerment of the individual being supervised and is crucial for a community of learning in general practice.

GP teacher and GP supervisor are used interchangeably in this guide, on the understanding that in clinical practice the role is varied and interchangeable. While the role mostly involves teaching about a particular patient’s care and therefore has a focus on a ‘supervision’; at times the GP supervisor will be involved in teaching on a theoretical topic, which in a stricter definition is more ‘teaching’-focused.

GP registrar is a vocational trainee undertaking training with either the Royal Australian College of General Practice or the Australian College of Rural and Remote Medicine with Fellowship as the end point of training.

RACGP—The Royal Australian College of General Practitioners is one of the two general practice colleges in Australia.

ACRRM—The Australian College of Rural and Remote Medicine is one of the two general practice colleges in Australia.

Training organisation—In Australia, GP training is currently delivered by regional training organisations (RTO).

Burton J & Launer J. Supervision and Support in Primary Care. CRC Press, 2004.

This book discusses the complexities of supervision entails and provides useful definitions.

References for Introduction