Dr Maura Harvey, GPTQ’s Senior Medical Educator (Supervisor Support) has a breadth of experience to share, from her time as a business owner of three practices in rural Queensland, to her current sojourns around Australia as a GP locum. Here she shares the importance of supervisors supporting and encouraging registrars to ask for help, without compromising patient confidence.
If registrars are reluctant to seek timely help, patient care and outcomes may be compromised, the registrar and practice may become exposed to medicolegal risk, and the registrar has lost an effective learning opportunity.
Registrars may be reluctant to seek help during a consultation for many reasons including:
- Time pressures
- Wanting to appear knowledgeable and capable to the patient
- Wanting to appear knowledgeable and capable to the supervisor
- Not wanting to interrupt the supervisor
- Lack of clear guideline on when and how to contact the supervisor for advice
- Over confidence
- Lacking insight regarding limitations or boundaries
- Fear of revealing knowledge gaps
- Cultural, personality or style differences.
Dedicated direct observation sessions, chart reviews, case based discussions, and specific enquiry or feedback may identify some of these with your registrar/s.
Orientation should include clarifying with registrars how to access advice, assistance and support. It can include who to ask for what type of advice and when to ask, for example; immediately, during the consultation, between patients, later in the day or at the next teaching session. It’s important to also discuss how to ask, for example; on a phone call, knock on door, corridor chat, internal messaging, or a list for later discussion.
Six stages to seeking and enacting clinical advice or assistance include:
- Informed patient consent
- Putting the problem to the supervisor
- Case presentation, help asking delivery
- Concluding the consultation
- Extended learning
- Reflection, improving the process
Informed patient consent for assistance can be approached in various ways which preserve the therapeutic relationship. Options can be discussed in advance with registrars and can include:
- “There are various options here. May I discuss this with / get a second opinion from Dr… ?”
- “Dr.. has a special interest in this. I’d like his/her input, if that’s ok with you?”
- “This isn’t common. Is it ok to call in Dr..and we’ll discuss it together?”
- “Dr.. knows more about the resources in this area. May I check with him/her and what/who/where will be best for you?”
- “It’s policy here that every case of… is reviewed with another doctor. May I call in Dr..?”
- “This is fascinating. I’d love to involve Dr.. if that’s ok with you.”
Specifying the type of requested help guides the supervisor, and is time efficient. For example:
- Taking over or sharing care e.g. “Can you do or help me to reduce this dislocation or remove this corneal foreign body?”
- Specific guidance e.g. “What is this rash? Which treatment to add now? How or where to refer a patient? What is the significance of this finding/result?”
- Systems issues e.g. “How to do a care plan, upload a referral, do an authority prescription online or on phone?”
Presentation vignette is practice for KFPs. You can help your registrar refine their case presentation and question along KFP stem lines or using a PICO approach. Population, Intervention, Control, Outcomes can become:
Assisting the registrar can occur in various ways, and will differ according to the clinical problem, stage of the registrar’s professional development, learning and teaching styles. Options can include:
- Managing with the registrar. This is the preferred collegiate style for most in-consultation interactions, with/without patient input, using open non-directive discussion, sharing opinions and appropriate affirmation.
- Supervisor leads registrar to supervisor determined outcome via leading questions.
- Taking over the consult. This can be time efficient and safe for patients but it compromises registrar confidence, therapeutic relationship, and learning so be mindful to use this option only when necessary and with caution.
Extended learning occurs when the case or topic is followed up with case-based discussion or focused reading or skills training.
Reflection on the help seeking process and outcomes can improve help seeking, clinical reasoning, focused learning, and the supervisor-registrar relationship. It will enhance clinical independence development, professionalism and promote lifelong learning.
Other supervisors will have many strategies to help registrars seek help. Share your knowledge!