Guide for Practice Managers and Supervisors

Guide for Practice Managers and Supervisors 1

Have you seen our new website? gpsupervisorsaustralia.org.au GPSA is the national representative body that unites GP Supervisors by promoting recognition for Registrar supervision work through open and accountable advocacy. 2

About this guide Whether your practice is new to supervision or your team is already training the next generation of family doctors, this guide will help prepare your doctors and practice to deliver a valuable supervision experience for your learner, your doctors and your team. While this guide is geared towards the supervision of registrars, parts of it remain relevant to the supervision of other learners, including doctors on the Prevocational General Practice Placements Program (PGPPP) and medical students. The overarching message behind the guide is that supervision work is integral to the health of Australia s primary care system. It is also recognised that supervision is mostly delivered within a private general practice business setting where commitment to patient care is paramount. Supervision needs to be at all clinical levels planned, committed to, varied and supportive in order for our future GPs to flourish and businesses to remain highly effective. GP Supervisors Australia Thank you to our funders Commonwealth Department of Health The preparation of this guide was made possible with funding from the Commonwealth Department of Health. Being a supervisor is very sustaining and most of us would say we learn as much from our registrars as they learn from us. There is renewal. It revitalises the practice. It s good for everybody. Dr Trish Baker, GPSA Chair and Practice Principal, Brisbane. 2014 GPSA 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 GPSA, or in the case of third party material, the owner of that content. No part of this publication may be reproduced without prior permission and full acknowledgement of the source: Guide for practice managers and supervisor s. GPSA has made all efforts to ensure that material presented in this publication was correct at the time of printing and has been published in good faith. GPSA does not accept liability for use of information within this publication. Due to the rapidly changing nature of the industry, GPSA does not make any warranty or guarantee concerning the accuracy or reliability of this content. 3

Contents 1. Becoming a supervisor Why supervise? What GPSA members say about supervision Overview of college requirements 2. Getting ready for supervision Selecting a new team member Employment contracts Prepare your team Practical things to consider Orientation 3. What can your practice offer? Supervisor levels Supervision of PGPPP and medical students Types of supervision Teaching methods 4. Getting started Learning plans Supervisor commitment Setting SMART goals 5. Time management Length of supervision periods Supervisors key roles RACGP and ACRRM requirements Tips for keeping on track 6. Preparing for the unexpected Practical challenges Personality difficulties Emotional intelligence References Appendix A Sample orientation checklist for registrars Appendix B Sample learning plan filled out by registrar 4

1. Becoming a supervisor Why supervise? Supervisors are not only GPs who teach, but medical leaders who inspire and support the next generation of GPs through their training. Supervisors offer committed one-to-one teaching, mentoring, supervision, support, feedback and advice. What GPSA members say about supervision GPSA asked our members what motivates them and what they enjoy about supervision. The majority said that they do it because they find it personally and professionally rewarding. See below for some of their responses. It is satisfying to be able to show registrars that they are not "just a GP" and encourage them to do more than just refer to a specialist. Supervision stretches my abilities and gives me the chance to engage with younger doctors. One day they (registrars) will look after me and my family, and Australia. Being a supervisor allows me to uphold the importance of family doctors and excellence in general practice. It s been rewarding to share my knowledge and expertise gathered through the years. I enjoy providing registrars with exposure to Aboriginal Health and seeing how they can develop a more effective approach. Overview of college requirements The Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) both have standards on supervision and training posts, as summarised in Table 1. More details can be found in the RACGP s Companion for Standards for General Practice Education and Training: Trainers and Training Posts 2005 (version 2), and in ACRRM s Guide for supervisors Australia General Practice Training (available online at acrrm.org.au). Regional Training Providers (RTP) conduct accreditations on behalf of both colleges. You may wish to review these standards. 5

Table 1: Overview of college supervision requirements and responsibilities Responsibilities Ensures structured orientation is provided to registrar. Supports and monitors the learning plan. Provides structured and informal feedback to RTP. Ensures teaching requirements for registrar are met. Provides oversight, guidance and feedback to a registrar on matters of personal, professional and educational development. Anticipate a doctor s strengths and weaknesses in particular clinical situations, in order to maximise patient safety. Provide structured educational activities for registrars according to their level of training. Assist the registrar to develop a learning plan and identify learning goals. Provide appraisal and formative assessment of the registrar. Participate in appropriate supervisor training and assessor training activities. Education requirements Other Participation in education-based professional development. May vary between RTPs. Maintain professional indemnity. Maintain current medical registration. Note: More details can be found in the RACGP s Companion for Standards for General Practice Education and Training: Trainers and Training Posts 2005 (version 2), and in ACRRM s Guide for supervisors Australia General Practice Training (available online at acrrm.org.au). 6

2. Getting ready for supervision From the practical and procedural to the personnel and personal, there are many elements that need to be considered when welcoming a new person to your practice. It s important to cover all these areas so your practice can guide and support new team members and still run effectively. Planning ahead and good organisation also leads to greater accountability and understanding of responsibilities. It clarifies the expectations among supervisors, the learners and the practice. Selecting a new team member When considering an applicant s CV, it s important to check that the applicant s interests clinical and procedural are aligned with what your practice can offer, and that you can support their level of training and experience. The interview phase, like any job, is a crucial time to sound out the applicant s personality, attitudes, motivations, learning and working styles and make sure they will be a good fit with your practice and supervisor. Note: If you are taking on a medical student or PGPPP, it is still important to take care with your selection and make sure the learner s experience which may be their first in general practice is a positive and interesting one. Employment contracts Registrars must be employed as employees of the practice and not as contractors. Employment contracts should be agreed to and completed before the registrar arrives on their first day so there are no surprises each party should understand the expectations and standards. Prepare your team As soon as you ve selected your medical student, PGPPP or registrar, let the rest of your team know when they can expect to start working with them. If you are offering shared supervision, it s a great opportunity for GPs to think about patients, or even a group of patients, who might be suitable for the learner to work with. This includes any interesting or unusual clinical cases. In terms of time management, the time you block off at the beginning of the placement for orientation and for supervising when the registrar is brand new, is paid back with interest when they get 'up to speed' earlier." Dr Ian Kamerman, Tamworth. 7

Practical things to consider When setting up your new learner, here s some practical things you need to consider to help them get settled quickly. Medical administration: Check that learner (registrar) has their medical provider number. Work space: Provide the office necessities, such as a room, desk, chair, computer, telephone and stationery and name badges. Private review area: Make sure there is a quiet room available for you to hold reviews with your learner and assess their goals. Processes and procedures: Make sure the learner, particularly for PGPPP and registrars, is aware of all procedures in the practice, such as tests and tests results, referrals, admission to hospital, after hours arrangements, patient follow up, sterilisation, S8 medications and waste disposal. Contact numbers: Get together a list of the practice s key contacts. It could contain names and numbers of nearby hospitals, specialists and relevant allied health organisations. Orientation General practices are busy and exciting places, but they can also be an overwhelming environment for a new team member. Take time to provide a thorough orientation. It will benefit the learner and everyone else in the practice. Orientation can be divided into three areas: The workplace: Show how the practice operates who s who and who does what, standard procedures familiarity with nurses station, break areas, filing and where to find reference materials, medications and equipment. The placement: Confirm the practice s supervision and teaching obligations and also the attendance and learning requirements according to the learner s university, hospital or RTP. The community: Help the learner to understand any relevant information about the community that may factor into clinical work and treatment. See Appendix 1: Sample orientation checklist Case study: Planning a registrar s first day I generally block out the supervisor s entire morning on the registrar s first day of work. This gives the supervisor a chance to go through our software system and make sure the registrar knows how to use it. I also block off time with the nurses so the registrar can become familiar with the treatment room. Towards the end of the morning, I ll book a few on the day patients for the supervisor. The registrar can sit in on the consultation and add notes on the computer. For the afternoon, I might book the registrar one patient, then a space, then one patient, then a space and so on. This gives the registrar time to catch up in between patients. On the second day and if the registrar is feeling comfortable, I might book two patients and then a space. I ll ask them how many free slots they think they ll need per hour. It s important not to put too much pressure on them. Margaret, Practice Manager, Brisbane. 8

3. What can your practice offer? Supervision work has many rewards, but it is also a time and financial investment for supervisors and practices. Different practices have their own approach to supervision and it may take some experience to learn what works best for your team or different learners. Supervisor levels Level 1 GP supervisors are accredited to train registrars in any stage of training (GP Terms 1 to 3). As they are supervising new registrars, these GPs need to have extensive teaching and supervision experience. Level 2 GP supervisors are accredited to supervise registrars who are in their later stages of GP training (GPT3 term) who have the equivalent of at least one year full-time GP experience. Most supervisors start as a Level 2 trainer. Supervision of PGPPP and medical students Registrars are an excellent choice for taking on a supervisory role for prevocational doctors and medical students, having recently been students themselves. It is also a good professional development opportunity for them. Types of supervision Registrars can either be supervised by one supervisor (sole supervision) or by one or more supervisors (shared supervision). Both options provide excellent ways for learners to grow. Whether using sole or shared supervision, involving other team members such as practice nurses and allied health even on an informal basis can broaden the learner s experience. Sole supervision Rural, solo GPs or GPs in small practices may be more likely to offer sole supervision one supervisor per learner. Sole supervision can enable the learner and supervisor to build a really strong relationship and provide a continuity of teaching. If operating in a sole or rural practice, shared or peer learning to support both the supervisor and learner can be made possible via video links, telephone, email and online tutorials. Shared supervision Shared supervision is where more than one doctor provides supervision for a learner. If using shared supervision, it may be preferable to appoint a lead supervisor to coordinate the supervision and make certain the learning plans established for the registrar remain on track. Shared supervision can expose the learner to different perspectives and treatment styles, as well as different ways of learning. 9

Teaching methods When it comes to clinical work, there are many ways to teach. Depending on what works best for their clinic, supervisors may use one or more of the following examples. Teaching on the run Involves quick exchanges between the registrar and supervisor, often by phone or door knocks. Wave consulting While the supervisor sees several patients, the registrar is booked one specific patient who they may see over a longer time period and then meet with the supervisor to discuss their notes afterwards. Remote supervision Involves the registrar being supervised via email, phone calls, video conferencing and visits by a supervisor in another location. A combination of teaching methods may be used to get the right balance. There is no hard and fast rule. Sometimes it takes some trial and error to work out what suits a particular practice, supervisor and registrar. As on old Greek once said: The mind is not an empty vessel waiting to be filled, but a fire ready to be lit. Supervisors provide the spark and practices provide the safe fireplace for this to happen. Dr Steve Holmes, Clare, SA. 10

4. Getting started Your new team member has arrived and you are ready to show them the wonderful world of general practice but where do you start? A good first step is to assess the learner s skills, experience and confidence. That way you can start to provide training that challenges and interests them, without moving too slow or too fast. Learning plans This section will focus on the registrar s learning plan; however, this learning tool is also important for medical students and doctors on the PGPPP to ensure they experience the great variation that general practice can offer. A learning plan, developed by the registrar and supervisor, helps the learner to navigate the direction they want their training to take. It can also help identify if they need additional work in a particular area and ensure that the supervisor is providing a comprehensive range of clinical teaching. In the first or second one-to-one session, the supervisor should go through the plan with the registrar. An updated learning plan usually needs to be submitted to the regional training provider (RTP) every month, but it s important to keep up to date with the plan on a weekly basis. See Appendix B: Learning plan example Supervision commitment Some supervisors may want to develop a supervision commitment with their medical student, PGPPP or registrar. This can help to ensure that both the supervisor and learner are aware of responsibilities and expectations. A supervisor commitment may cover: 1. Goals for sessions. 2. Practicalities (what the supervision and placement will look like and the learner s main contact people). 3. Supervisory relationship (boundaries and expectations). Setting SMART goals There are many good methodologies that can help the supervisor and learner to set goals. One such example is SMART. It requires goals to be, Specific, Measureable, Achievable, Realistic and Time based. Table 2 Example for SMART goal for GP registrar Specific Measurable Achievable Realistic Time based To understand the medication protocols for complex diabetic Can confidently manage complex patients without supervisor assistance 80 per cent of the time. Has access to and understands how to use a reference guide on this topic. Can be assigned the existing regular patient cases. Goal will be achieved within one month. 11

5. Time management Keeping on track in a busy practice is hard work, and adding a learner to the mix can require extra effort by the whole practice team. Depending on the level and style of supervision, supervisors may get a fairly steady flow of knocks on their door from learners needing advice. It s important that if you are going to commit to taking a learner, you can put in the time needed for the entire supervision period. Length of supervision periods Registrar placements can be from six months or even one year and doctors on a PGPPP usually spend about 12-weeks their practice. Medical student placements can range from three to eights weeks, or even over the course of a year. Supervisors key roles. A supervisor s work, be it with medical students, doctors on the PGPPP or registrars, can broadly be divided into these three areas: Clinical guidance and support This means being on site with the learner most of the time, or at least contactable if not on site. Performance review Review the learner s performance in line with goals set in the learning plan and their general development as a GP. Provide assistance to review and develop their learning plan. Professional development Spend some time on activities which develop the supervisor s own skills as a clinical teacher. RACGP and ACRRM requirements The amount of time and type of supervision to be given to a registrar varies depending on the stage of their training and their experience. Both the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) have teaching and time requirements that supervisors must follow. See the following page for details. Every week, I ask the supervisor about the clinical areas they have covered with the registrar. I jot the points down there and then it s much easier than trying to remember what was taught week or two ago. Margaret, Practice Manager, Brisbane. 12

RACGP A summary of teaching and learning time for registrars following the RACGP pathway is shown in Table 3. Full details can be found in the RACGP s Companion for Standards for General Practice Education and Training: Trainers and Training Posts 2005 (version 2). Table 3: Teaching and / or learning time per week by term (GPT1) (GPT2) (GPT3) In practice teaching time 1 hour 1 hour N/A Other teaching time 2 hours 0.5 hours N/A Other structured learning time N/A N/A 1 hour Total (teaching/structured 3 hours 1.5 hours 1 hour* learning) time Source: RACGP Note: GPT 1 and GPT 2 registrar placements include a minimum 1 hour of protected teaching time. Each week, the trainer must provide a 1 hour block of uninterrupted face to face teaching to the general practice registrar. Rural and remote posts can apply to be prospectively approved to provide 1 hour of protected teaching per week time via telephone or video link through the appropriate RACGP Faculty Accreditation Officer. ACRRM ACRRM has set out how the supervisor must comply with the structured educational activity requirements for Primary Rural and Remote Training (PRRT). This is summarised below but more detail can be found in ACRRM s Standards for Supervisors and Teaching Posts Primary, Rural and Remote Training (PRRT), V01/2013. 13

Vocational Preparation Pathway (VPP) Supervisors training registrars on the VPP are required to provide structured educational activities that meet the criteria shown in Table 4. Table 4: VPP requirements Stage of training First 6 months of PRRT Second 6 months of PRRT After 12 months Hours 3 hours per week 1.5 hours per week According to the registrar s needs Remote Vocational Training Scheme (RVTS) Supervisors training registrars on the RVTS pathway are required to maintain regular contact with their registrar as shown in Table 5. Table 5: RVTS requirements Stage of training First 6 months Second 6 months Hours 1 hour per week 1 hours per fortnight Remainder of the program 1 hour per month Other requirements Participate twice yearly in three-way teleconferences between the registrar, supervisor and an RVTS medical educator. Visit the registrar once per year as part of a clinical teaching visit. Join weekly tele-tutorials for which their registrar is presenting a case (twice per year). 14

Independent Pathway (IP) Supervisors training registrars on the IP are required to demonstrate how they provide or intend to provide structured educational activities meeting the criteria shown in Table 6. Table 6: IP requirements Stage of training First 6 months of training Second 6 months of training After 12 months Hours 3 hours per week 1.5 hours per week According to the registrar s needs Note: this is based on a registrar undertaking a full four years of training towards FACRRM. Where the registrar is exempted one year or more of training time, structured education should be provided according to the needs of the registrar. Practice manager s tips to help supervisors DO Schedule catch-up time for the supervisor every day. At least half an hour in the morning session is a good start. DO Try and move patients (if they agree) to a less busy colleague if the supervisor is behind. DON T Give into temptation and squeeze an extra patient in with a supervisor on busy days. 15

6. Preparing for the unexpected Even practice managers and supervisors who plan ahead may still encounter unexpected challenges. These challenges can range from the practical to personal. Practical challenges Supervisor or learner needs time off work for illness or family matter Sole practitioner needs to go off site for a short training course, leaving learner alone Strategy: Plan ahead Plan to get ahead on supervision contact hours early in in the registrar s placement. This has the added benefit of extra support early on in the placement which can boost learner s confidence and capabilities. This will also help cover any holidays taken. Note: If by planning ahead you reach the total supervision hours required before the placement has finished, supervision must still be given each week according to the college requirements even if it means total hours exceed the requirements. Personality difficulties Personality clash between supervisor or other staff and the learner Learner overwhelmed and not enjoying experience Occasionally, as in any workplace, difficulties may arise with a poor fit between supervisor/ practice and the learner. Personality differences or a miss-match of expectations do happen and one can't always foresee these difficulties. If this happens don't' get too stressed. The placement isn't for ever. However, do remember that the supervisor needs to remain in the role of employer and mentor.. Help is never far away. Debrief with a supervisor colleague, your Supervision Liaison Officer or a Medical Educator. Keep all communication with the learner clear, friendly and respectful. Work on maintaining the professional side of the relationship teaching sessions, corridor consultations, phone calls, second opinions, while enlisting the help of the practice manager and staff to nut out rosters and to include the learner in the tea room conversations or practice social activity. Stay positive - it is unlikely to happen again. Emotional intelligence In addition to excellent clinical and teaching skills, supervisors must possess the personal skills needed to work closely with and mentor another person whose learning style and approach may be different from their own. A degree of emotional intelligence is needed to address personal problems between a learner and supervisor or identify if other factors, such as learners experiencing homesickness on rural placements or feeling out of depth, are contributing to the learner not progressing as expected. More information in this area can be found online in GPSA s Best practice for supervision in general practice. Go to gpsupervisorsaustralia.org.au/resources/professional development/guides to download a copy. 16

Good luck! We hope this guide has provided some useful information about the first stages of getting your practice and team ready for supervision work. As a next step and for more professional development, see GPSA s Best practice supervision guide for practices. It can be downloaded online at gpsupervisorsaustralia.org.au/resources/professional development/guides Thank you Thanks to the people who helped write and edit this publication and provided quotes. A special thanks to Margaret Dillon, a practice manager with more than 20 years experience, for her input. Dr Trish Baker, Chair GP Supervisors Australia Margo Field CEO GP Supervisors Australia Dr Ken Hazelton GP Supervisor Orange NSW Dr Steve Holmes GP Supervisor Clare SA Dr Ian Kamerman, GP Supervisor, Tamworth NSW Laura McGeoch, Media Advisor GP Supervisors Australia Rob Were, Research Project Officer, GP Supervisors Australia And numerous anonymous GP supervisors from around Australia. Practices really need to put time into a registrar and not just see them as an extra source of labour. Registrars can bring a lot into the practice. Many of our current doctors were registrars here and they are great. They are also excellent with helping medical students as they have recently been students themselves. Margaret, Practice Manager, Brisbane. 17

Appendix A: Sample orientation checklist for registrars Practice Organisation Completed: Tick History of practice and general structure Introduction to all staff and their roles Practice Information sheet Practice and procedures manual Facilities Completed: Tick Lunchroom facilities, toilets Car parking arrangements Fire/emergency procedure Working Conditions Completed: Tick Working hours, breaks, roster changes Method and timing of salary payment Policy and procedure for leave arrangements Registrar teaching dedicated time blocked off Policy on grievance procedures Doctor s trays correspondence Reporting incidents and adverse patients Safety and privacy information Completed: Tick General safety rules and OH&S guide/manual Overview of medical and non-medical emergency procedures Blood and body fluid precautions Procedure for needle stick injury Use of practice equipment and systems Completed: Tick Telephone Fax, photocopiers and scanner Appointment system and booking procedures preferences Requests for reports, w/comp telephone advice (how to bill) Procedure for X-rays and follow up How to enter HIC items numbers and billing Phone messages 18

Appendix A continued: Sample orientation checklist for registrars Principal Completed: Tick Overview of practice philosophy, type of patients and areas of special interest care etc. Patient record systems and procedures Computer medical software program Accreditation process and responsibilities Local networks and professional support Reference books/resources/online Learning plan Nurses Completed: Tick Tour treatment room Spills kit Oxygen and emergency room equipment, PPE Brief on steriliser/log book Specific equipment: speculums, hyfrecator Spirometery ECGs Ultrasound Pathology results protocol Recall of clinically significant results General recall and reminder systems PAP result entry RN appointments Vaccinations, batch number records Contaminated wastes, sharps disposal Infection control/spills kit Stocking of rooms Drug cupboard documentation required Registrar signed off and date: Principal signed off and date: 19

Appendix B: Sample learning plan filled out by registrar Registrar Name and RTP: 1) Identification of learning objectives Learning objective 1: By (xx date) (timed) I will be confident in my ability to manage back pain in 90% (measurable) of patients from all causes through the use of a diagnostic triage process (achievable) differentiating for simple backache nerve root pain possible serious pathology e.g. lumbo-pelvic cancer, kidney stones (specific) and competently refer to patient to specialist care as necessary (realistic). Learning objective 2: In 3 months (timed) I will be able to demonstrate that 95% of patients (measurable) attending the clinic treatment room for treatment of soft tissue injuries are managed by me with the highest level of skill and care (treatment overseen by the treatment room supervisor (specific). I will achieve the necessary skill level by alerting practice staff of my interest in treating soft tissue injuries and will make myself available to observe and/or treat as appropriate. (realistic) 2) Resources/methods for meeting objectives Supervisors Other GPs Therapeutic guidelines Up to date with Murtagh 3) Methods for measuring progress Feeling more confident in my ability. Asking less questions and being able to manage different GP scenarios better. Registrar signature: Date: Supervisor/training advisor signature: Date: Please forward this form to your training provider and keep a copy for your records 20

References On Track elearning Package, WA Clinical Training Network, Western Australia Department of Health (health.wa.gov.au/wactn/home/resources.cfm) Standards for Supervisors and Teaching Posts Primary, Rural and Remote Training, V01/2013, Australian College of Rural and Remote Medicine Companion for Standards for General Practice Education and Training: Trainers and Training Posts 2005 (version 2), Royal Australian College of General Practitioners. Supervising GP registrars at a glance, GP synergy, pdf. In-practice teaching guide, a publication of General Practice Registrars Australia CCCGPT GP Supervisors Handbook, CoastCityCountry Training Supervision growing and building a sustainable general practice supervisor system, Medical Journal of Australia, Volume 194 Number 11 21