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Registrars with confidence problems can struggle with their own learning, wellbeing, affect the practice’s team culture and patient safety. Underconfident registrars outnumber overly confident registrars. Identifying problems early, exploring the underlying issues and managing them prevents larger problems and enables better outcomes.

Dr Maura Harvey outlines how to recognise and respond to confidence problems and shares useful resources for supervisors.

How to recognise registrars struggling with under-confidence

Under-confidence can present with either not enough or excessive requests for help, absenteeism, avoidance of certain patients and procedures, irrational investigations or treatments, inflexibility, low productivity, poor time management, inappropriate emotional responses, intolerance of uncertainty, underbilling, disengagement from the practice team or education activities, lack of initiative, anxiety, career disillusionment or doubt and exam failure. Lack of appropriate requests for support can also be an indicator of over-confident registrars.

Formal and informal collateral information can help identify registrars with confidence problems. Examples include random case analysis, case-based discussion, education sessions, direct observation, chart reviews, staff shielding or bypassing the underconfident registrar from certain requests, feedback from patients, comments from staff and peers, medical educators and ECT visitors.

Exploring possible causes of confidence problems can help rectify them. Often there are personal problems, interpersonal conflicts, previous adverse experiences, family, health or financial issues, and adjustment to relocation and the individualistic consultation style of general practice. Practice issues can include inadequacy of orientation, role descriptions, training in systems and software, rostering and timely support. Professional issues can relate to motivation, attitude, communication and boundaries while performance problems include gaps in knowledge, skills and clinical reasoning.

How supervisors can help registrars

Managing confidence problems with registrars starts with the supervisor. The supervisor can plan a session with the registrar which is confidential, formative, collegiate, collaborative, and start and finish on a positive note.

Ask the registrar to reflect on their overall progress and confidence. Acknowledge, affirm and highlight achievements or actions leaning in the desired direction. By seeking permission before the supervisor reflects on challenges and issues, registrar buy in to the following discussion increases. It may be helpful if the registrar is prompted to deconstruct past experiences where the registrar developed confidence and which learning styles suit the registrar. This information can guide subsequent teaching sessions and support. Establish frequent smaller SMART goals with timely feedback which is planned, noting that registrar training is a journey with a progression of competency stages.

Strategies to help resolve confidence problems
  • Creating a “Call for help” list based on identified knowledge and skills gaps
  • Training in practice systems and software, specific guidelines and resources
  • Direct observation and reverse direct observation
  • Shared consultations or procedures

Skills in clinical reasoning and managing uncertainty can improve through use of random case analysis, case-based discussions with variations from the 5 domains of GP.  Highlight cognitive dissonance, encourage insight and self-reflection.

As a supervisor it may be appropriate to explicitly discuss self-care strategies and model good self-care yourself. You may suggest other supports like the medical educators, registrar liaison officer,  GPRA, the registrar’s own GP, or the GPTQ EAP – Assist EAP.

Please get in touch with your local district medical educator or the supervisor support team at GPTQ if you would like to discuss this further.

Resources

GPTQ Medical Educators – Supervisor Support team – supervisorsupport@gptq.qld.edu.au

GPSA webinar:  Identifying and Supporting Registrars At Risk

Self-assessment tool:  https://www.thinkmentalhealthwa.com.au/mental-health-self-assessment-checklist/ 

GP registrars Australia (GPRA):  https://gpra.org.au/

Access EAP:  https://www.accesseap.com.au/

Doctors for doctors:  https://www.drs4drs.com.au/