On this page:

A final story

The enjoyment of teaching

Becoming a ‘master’

Suggested further reading

Sally, a GP supervisor, had a flat-out day seeing a variety of patients. Sally was running behind at least 30 minutes in her appointments for most of the day. She had a fourth-year medical student, Matthew, working with her for his first day in general practice. Matthew had been very helpful at times, and asked lots of questions, although Sally felt she hadn’t had the time to answer these questions thoroughly. Mid-morning, Matthew had made Sally a coffee, which was very thoughtful. At lunchtime, Sally only had 10 minutes to grab something to eat, so she told Matthew to take off for a longer lunch break. However, Matthew said he preferred to stay and start the afternoon session with Sally, because he was finding the patients so interesting. At the end of the day Sally felt tired and emotionally exhausted, rather like the last patient whom she felt she hadn’t quite managed completely. Sally asked Matthew if he had any more questions. Matthew responded, “No, but thank you for such an amazing day. It is so interesting the different things we saw today and the different issues you sorted out for people. How do you keep it all in your head? How do you stay so up to date? I don’t know if I could ever be a GP—it is so complex. However, your patients really trust you and you know them so well. It is really impressive, and I learned so much. Thank you.” Sally noted feelings of tiredness on the way home, but she also felt an inner glow of contentment. “A worthwhile day,” she said to herself.

One of the best things to do with a medical student at the end of the day is to ask, “How did you find today?” You may be thinking that the story above isn’t reality! However, it is exactly what most medical students think when they commence in general practice, even if they don’t express it directly to the GP supervisor. We often remember the cynical or arrogant student, but these types of student are rare. Most medical students are open-minded and keen to learn how to be doctors. They like to contribute and find meaning in their day. Similarly, we as teachers want to feel that we have contributed to a student’s learning experience, and that they have found it meaningful to work under our supervision.

Doctors in general are high achievers. We like to do well at what we do, and we like to do the best for our patients. However, it can be lonely at times in general practice. Sharing your day with a student can be very satisfying, particularly if the student appreciates the complexity and richness of general practice and the patient journey. Supervising and mentoring a junior doctor as they progress to competent clinician is a rich experience that can reduce the isolation and loneliness of general practice. The opportunity to work through difficult patient issues and to explain your own approach to patient care is a useful reflective tool in which all clinicians should engage. It keeps us thinking rather than just following our usual routine.

Motivation to teach

Most GP supervisors love teaching because they learn. Explaining to a student what you are doing and why is one of the best forms of reflective practice. Asking a student for their opinion on what they have been taught helps supervisors keep up to date. For example, asking learners to look up the latest evidence can be a strategy for the GP supervisor maintaining currency. Teaching helps to keep our intellectual minds active. In this book, we have explored many good reasons to be a teacher, establish an ML teaching practice and be a part of a community of learning. Ultimately, we need to understand our own personal motivation and what makes it worthwhile to engage in teaching, particularly on those days when we feel overwhelmed and on the edge of burn-out.

Abraham Maslow, an American psychologist, published a paper in 1943, ‘A theory of human motivation’. The paper described the fundamental human needs for growth and development as a person. Although described as a hierarchical pyramid, these human needs in fact are interrelated, and people can move between the stages defined by Maslow at different times. Maslow’s pyramid is a framework that can be applied in the context of describing how doctors evolve into competent teachers.

Basic needs

Maslow identifies that humans have basic physiological needs such as food and clothing and requirements for safety or security—all key elements of survival. In medical training, a student commences with a need to develop basic skills such as history taking, examination and diagnosis so as to ensure serious conditions and potential patient harms do not go unnoticed. The next step in Maslow’s hierarchy is love and belonging. In the context of general practice, junior doctors or registrars reach this level when patients choose to return to them in future consultations. When patients express a preference to see a junior doctor as their treating doctor they feel accepted by patients. When registrars attain Fellowship of the RACGP or ACRRM, the feeling of belonging to the profession grows.

Building and maintaining esteem

The next step in Maslow’s hierarchy is called esteem, and this stage is complex. It is about feeling confident, respected and fully competent. In general practice the esteem stage relates to receiving respect from colleagues, and patients wanting to see us. GPs who are booked out feel confident that they are doing a good job. Over time, our sense of confidence and competence builds from specialist letters and discharge summaries confirming our diagnoses and treatment plans, and, more importantly, patients returning to report that our management has cured or helped. Most doctors initially look for external validation. Over time, validation becomes internalised, as we mature as doctors.

Doctors learn that they cannot always make patients happy, that there are times when they must say no, that not all patients can be helped or cured and not all patients listen or take their doctor’s advice, no matter how expert and well-meaning. If our internal sense of esteem is functional, we know that that is okay—it doesn’t make us a bad doctor. However, if we are constantly looking externally for respect and affirmation there is a risk of becoming burnt out or critical of our own competence. An extra challenge for general practice is being devalued and criticised by the tertiary health system. In this context, teaching can be an important way to enhance our personal confidence and respect for ourselves as competent practitioners.

Self-actualisation

Maslow identifies self-actualisation and self-transcendence at the top of the hierarchy of human needs. Self-actualisation encapsulates mastery and giving of oneself to the things about which one is passionate. Self-actualisation encapsulates working for the greater good or for the future. In the context of general practice, Maslow’s pinnacle human need corresponds to the GP’s dedication to the job of medicine, and putting patients’ needs ahead of others. This stage reflects the role GPs play in creating lasting change in the health of their community. This stage also reflects passing on of one’s skills and knowledge to the next generation to enable future patients to receive high-quality care.

From a teaching perspective, self-actualisation and self-transcendence corresponds to the ‘master’ practitioner passing on knowledge (and so much more) to the student. GP teachers pass on wisdom, values and a passion for the medical profession. Not every student or junior doctor takes up the mantle, but the learner recognises the mastery of the practitioner and sees something intangible and awe-inspiring beyond the technical skills. For the GP teacher, these moments are not necessarily obvious, and there is no tangible, direct feedback. However, years later students will talk about the ‘gold standard’ doctor who taught them so much, even though they can’t exactly name what they learned. Ultimately, modelling and mentoring has the profoundest effect on students. Recognising oneself as ‘master’ and having the opportunity to pass this down to the next generation of doctors, while receiving limited reward, is one of the deepest benefits of being a GP teacher.

As a teacher, one of the most rewarding moments is when a student reaches their ‘Kairos’ moment. Kairos is an ancient Greek word meaning ‘the right, critical or opportune moment’. In his book, The Inner Apprentice, Roger Neighbour refers to this moment as the moment in a learning situation in which the student sees the core of the problem and realises how important it is to their understanding and learning. This moment is pivotal to the learner’s development as a doctor, although they are not always obvious and may just as likely relate to small things as to the large. Nevertheless, the teacher experiences satisfaction in seeing the ‘penny drop’ or the ‘lights go on’ for the learner.

Teaching itself is a skill that reflects Maslow’s hierarchy of human needs and personal development. Mastery as a teacher is reached when the teacher facilitates students to find these ‘Kairos’ moments. Teaching in medicine is ultimately about creating an independent practitioner who can develop their own learning by asking the right questions of themselves in a reflective way. Its ultimate reward is that we also keep asking ourselves the same questions.

Maslow A. A theory of human motivation. Australia: Simon and Schuster, 1943 (republished 2013).

This paper is worth reading to gain some theoretical framework for understanding human motivation. It is applicable to many contexts

Thomson J, Haesler E, Anderson K & Barnard A. What motivates general practitioners to teach? Clin Teach 2014; 11:124–130.

This qualitative study particularly looks at Australian GP supervisors and what motivates them to teach and what might sustain that teaching commitment

Neighbour R. The Inner Consultation. MTP Press, 1987.

This text is an essential text for supervisors as it looks in detail at what can be learned from the patient–doctor consultation

References for Moving to Mastery