Going the extra mile to support GP supervisors and registrars is all in a day’s work for rural Victorian practice manager Gayle Bloch. While passionate about helping registrars enjoy their experience in general practice, she is equally committed to nurturing their sense of community belonging.
The theory, of course, being a registrar who immerses themselves in the community is more likely to stay beyond fellowship.
“We try to encourage registrars to live here rather than commute. You see the difference; the ones that live here, are more likely to stay,” Gayle said.
“We want them to feel welcome and encourage them to get along to things and be a part of the community.”
For Gayle, this commitment has even resulted in coming out of netball retirement to join a social team with a couple of new registrars.
“I just thought it would be easier for them to play with someone they knew, rather than all strangers,” the Wonthaggi Medical Group (WMG) practice manager said.
In April Gayle was presented a Practice Manager Award at the 2019 Victorian Rural Health Awards, recognising her work in managing 33 staff members, 15 nurses and 25 doctors across three clinics; servicing Bass Coast Health as the exclusive provider of visiting general medical officers, obstetricians and anaesthetists to the hospital; servicing four aged care facilities; and as a qualified accreditor with Quality Practice Accreditation which requires her to do assessments of other clinics.
During her past 10-years in management at WMG, Gayle estimates she has worked with 40 to 50 registrars. She is proud nine former registrars are now permanent doctors at the clinic, including four recruitments from last year.
One of last year’s registrars is now preparing to become a registered GP supervisor at the clinic.
“It shows he has seen the value of the program,” Gayle said.
“We are a large teaching practice. I have been here 23 years and we have always been involved in some way in teaching; it’s a big part of who we are, and it’s an important part of who we are.
“We are a large practice, but we are like a family, so one of the important things is to make it an enjoyable and a really positive learning experience for the registrars to become a part of the community.”
Even with a wealth of experience in supporting registrars and supervisors, Gayle is always looking at improving the journey for all parties.
For example, recently she has changed the timing of when to explain hospital billing to new registrars, so the lesson is more effective. Now, instead of a full explanation of clinic and hospital billings during the practice induction, the hospital element is taught soon after hospital visits start.
“Before we were just feeding them the information (during induction) and expecting they would retain it. Now we are making an appointment with the accounts manager to teach them the hospital billings a few weeks after they start the hospital work; we have found getting the timing right is really beneficial because they have seen patients and will then have questions.”
While it’s important to make a new registrar feel welcome and supported, Gayle said supervisors also needed extra support when a registrar started.
“It takes a little bit of time for registrars to get their head around that they have 20 to 30 minutes with a patient, and they are in charge of that patient. They get a lot thrown at them, so we make sure we find them and check in with them a lot.
“We hold spots out in the supervisor’s schedule, so they have time when the registrar knocks on their door with questions.
“You have to be mindful of supervisors and the pressures they face when a registrar starts.”
Practice managers also need to remember each registrar comes with varying levels of confidence and competence, which in turn impacted the amount of support needed from, and for, the supervisor, Gayle said.
‘“Some will come already quite independent and don’t need much support, whereas others will be in your office for all sorts of things.
“Some won’t have families here and they need that sort of support too.”
And that’s where going the extra mile is in Gayle’s nature.
“I could tell you a lot of stories!” she said. “I’ve even organised the changing of a flat tyre for one registrar who was booked out with a hospital procedure and clinic appointments and needed to get to Melbourne at the end of the day to see family. I thought, ‘What’s more important? Him seeing patients.’ ”
Headaches arise when expectations don’t match
A common theme to problems faced by training practices stems from failing to determine at the interview if the registrar and practice are on the same page.
Some interviewers will only find out about the interviewee, and fail to explain the practice’s values and expectations; this initial lack of clarity can be the catalyst for disgruntlement and problems during the training term.
GPSA occasionally receives calls from practice managers about misunderstandings from registrars which could have been avoided if practice expectations and values had been explained at the interview.
One example is a registrar misinterpreting the wording of their contract which stated “You will work no less than two Friday nights per month”. Unfortunately, this registrar interpreted this to mean ‘working two Friday nights a month’ – rather than ‘two Fridays were a minimum’ – so when he received his first roster with four Friday night shifts he complained.
This is why GPSA recommends interviewers show, and explain, a draft version of the contract and a sample roster at the interview to ensure a clear understanding of expectations before a contract is offered and signed.
Interview tip: Tell the registrar about your practice
Often there is a good reason why a certain policy, rostering and patient booking approach etc are in place. Every practice is different, but your policies and your rosters reflect the realities of the practice.
It is not the role of the practice to bend itself to the needs of a registrar, but it is good practice to ensure prospective employees (registrars) are aware of the particular practice environment they are signing up for before they accept a start date and sign the contract.
GPSA CEO Glen Wallace said a registrar may be entering into general practice for the first time and not know what to expect, but equally they may have only worked in a practice that didn’t do after hours on-call work, or didn’t operate from 8am to 8pm, seven days a week, so sometimes a registrar doesn’t know to ask specifics about the conditions. Both parties can assume knowledge and assume shared meaning when in fact you both have quite different expectations.
“It’s these misunderstood expectations that bring practice and registrar relationships undone in the end,” Mr Wallace said.
Eastern Victoria General Practice Training (EVGPT) accreditation and practice support co-ordinator Dr Heather Grusauskas agrees a two-way conversation is most desirable to occur at the interview.
She said while interviewers needed to find out about the registrar, interviewers should also give a clear picture about how the practice and supervision operated.
“It depends on what experience the registrar wants from the practice; and what we want is a match where the registrar and practice enjoy mutual benefits,” Dr Grusauskas said.
“Issues can arise when both parties have different expectations. At interview, the registrar can get a feel for your individual practice and vice versa, and it might be that you are not a good match.”
Dr Grusauskas cautioned practice managers and supervisors conducting interviews not to assume the registrar had adequately researched the practice before their interview.
“When applying for a new job, most of us would do our homework before a job interview and find out how the business functions to get a feel for if it will be a good fit.”
“However you can’t simply assume the registrar has done their due diligence.”
Dr Grusauskas urged interviewers to talk to the registrar about the practice because the experience the registrar is seeking may not necessarily match what the practice could offer.
“You need to tell the registrar about your practice background, patient demographics, and how the practice works because each practice and registrar is uniquely different.
Dr Grusauskas said interviewers should remember every registrar had unique backgrounds, experiences and expectations – and every practice was unique; so it was vital to be clear in the interview about your working environment.
“Explain the rostered hours fully,” she said. “You need to be clear if your practice has a weekend roster, if it is a nine-to-five clinic or whether it is an after-hours clinic. All this needs to be a part of the employment conversation.”
Interview tip: Team effort
Dr Grusauskas said that ideally, more than one person should be involved in interviewing the registrar to help determine if the candidate and practice are a good fit.
“”It varies from practice to practice, but it’s advisable to have a mix of people doing the interview, such as the practice manager and supervisor because you are both going to be working with the registrar.”
Dr Sultan’s Quest to ensure each registrar reaches their potential
GP registrars under Dr Mohammed Sultan’s supervision experience a prime example of cradle-to-grave care in a small community.
In one instance, Dr Sultan treated up to four generations of one family – and happily accepted the family’s invitation to attend a milestone celebration for the family’s oldest member.
As the treating GP until the patient moved into a nursing home at 99, Dr Sultan had little hesitation in clearing his calendar to attend his former patient’s 100th birthday.
“We are a family orientated clinic, treating a few generations of some families,” Dr Sultan said from his clinic in Gatton, Queensland.
“This was my first experience of a patient under my care reaching 100 and I was pleased to be there with his family to celebrate his 100th birthday in 2016.”
Family Health Gatton serves a rural population in the Lockyer Valley, about 90km west of Brisbane, and has a wide demographic base in age, gender and medical conditions treated.
Dr Sultan, who trained and graduated in South Africa has practised in Australia for 20 years, and has supervised GPs for about 12 years.
In this time he has supervised between 20 to 25 registrars, and is a recipient of the GPSA Recognition of Service Award (10-plus years).
“It’s absolutely enjoyable to help young doctors grow and mature into great doctors; seeing them along their journey and knowing you have contributed to their learning as a GP,” Dr Sultan said.
“I always say to my young registrars that they probably know a lot of theory of medicine being fresh from uni, but I’m here to share my experiences as a GP, and teach them the practicalities of general practice along with the business and relationships required for them to ultimately be the best doctor he or she can be for every patient under their care.”
Dr Sultan said his journey as a supervisor was prompted by the excellent training he received as a medical student and young doctor in South Africa “from an amazing group of educators and consultants”.
Having trained in an environment where the learner is shown the procedure once, replicates the procedure, and pays the knowledge and skills forward to future doctors underpins Dr Sultan’s motivation to supervise registrars.
“My motivation to supervise is to educate the future community of doctors to be better skilled and knowledgeable of general practice.”
While supervising the future generation of doctors was a rewarding journey, Dr Sultan said it also brought challenges.
He said these challenges included dealing with different levels of knowledge and skill sets among new registrars, helping registrars better understand the transition from a hospital environment to GP setting, and dealing with the different administrative roles.
Dr Sultan’s advice for other supervisors?
“Patience with new registrars; share practice tricks and tips; and make sure that you pass on education of management of GP business and also employee responsibilities, as they differ so much to hospital.”
After 36 years as a GP supervisor Dr Geoff Norman is first to admit a supervisor does not need to know everything; but should be ready to learn.
“Remember you do not have to be a great learned teacher. I certainly am not,” the Nambour Medical Centre doctor on Queensland’s Sunshine Coast said.
“A supervisor is one who supports and guides.”
Geoff, a recipient of the GPSA Recognition of Service Award (35-plus years), is currently supervising his 39th and 40th registrars.
The supervision stalwart advises peer supervisors to learn with their registrars, tap into training resources, and encourage a practice culture where everyone is on board with GP training.
“It keeps me young; it’s enjoyable. One of the reasons why I keep going is because we are well supported in the practice, and have other doctors that share the teaching load,” Geoff said.
His journey to supervision stems from a love of tutorial learning acquired in high school. With four students and a passionate teacher, Geoff thrived in the small-group learning environment of his advanced geography class. Fast forward to his role as a supervisor, and Geoff brings the same benefits of tutorial learning to his registrars.
In his early career as a GP in a small practice, Geoff took on the occasional registrar, primarily to help manage the case load.
When the practice amalgamated with another small practice in 2012 with whom it previously shared a registrar, the new practice continued to embrace registrar training. This dedication is evident in the Nambour Medical Centre tea room where every registrar, mostly GPT1s, is recognised on an honours list.
“I have always enjoyed providing guidance to young GPs as they start their journey,” Geoff said.
“They have differing backgrounds, experiences, skills, and personalities.
“Having registrars provides a challenging refresher every year to general practice. It also helps stimulate my personal learning.”
Geoff said he was also stimulated by the challenges and rewards of supervision; he enjoys helping registrars grow in confidence, patient load and being accepted into the practice by patients.
“There is always a balance between letting them develop their own skills, preferences, and style whilst endeavouring to ensure they fit within our practice’s expectations,” he said.
As Geoff edges towards four decades of GP supervision, he has many practical tips for his supervisor peers.
“First and foremost, get everyone in the practice encouraging and accepting registrars,” he said.
“We have five registered supervisors and all our doctors are keen to teach: it is such a comfort to both me and the registrar.
“It is an enjoyable experience for all. We are all learning together.”
Geoff advised supervisors to get to know their registrar on arrival; ask about their medical, social and personal background to develop a picture about their learning and support needs.
He also advised supervisors and their training practices to “be organised so that you cover the basics in the first few months”.
This includes using an orientation checklist (see example at https://gpsupervisorsaustralia.org.au/orientation-checklist/ ) and “always having cases and techniques “up your sleeve so that you are never lost for a teaching session”.
“Keep calm and relaxed. Be accessible,” Geoff said.
“Don’t let little issues irritate but be firm when something important needs to be addressed.”
One of the most common critiques of supervisors by GPT1/ PRRT1 registrars is that they are not getting their three hours of in-practice teaching.
In reality, when they are investigated, most practices actually are fulfilling their in-practice teaching, but like feedback, many registrars don’t recognise when it is being given.
Add to this a registrar’s reluctance, fear or incapacity to provide feedback to their supervisors and you have a recipe for a festering wound that left unchecked can bring the whole training term undone, a terminal employer-employee relationship and dissatisfaction for all concerned.
Here is a checklist of how to pre-empt this common issue and navigate it before it becomes an issue:
1) Make sure feedback and teaching are explicitly featured as a topic of discussion during your registrar’s orientation.
2) Ask your registrar how they like to give and receive feedback. Think setting, mechanism, language, timing and scenarios. Sometimes your registrar might find it difficult to articulate what they do want, so you can start with what they don’t want. You can instigate this conversation by sharing stories of what you experienced as you progressed throughout your career in terms of challenging feedback situations that weren’t handled appropriately to enable them and make them feel comfortable about sharing some of their own vulnerable feedback experiences. Understanding their triggers and what hasn’t worked for you and them, and why, will help you land on a strategy that works for you both.
3) Design together where, when and how that feedback will take place. How will you as their supervisor provide feedback in front of a patient when your registrar has suggested a course of action that is not appropriate?
4) Pull out a verbal signpost when you are giving feedback so your learner knows they are receiving feedback: “I am giving you feedback now.” For example, someone might say “Some of the staff have commented that your clothes set you apart from the rest of the doctors at this practice.” If that’s what the registrar was going for, then they may receive that as a compliment. If they don’t particularly like the way others dress, they may also identify that comment as invalid and not receive it as feedback.
5) Ask your registrar what teaching interventions work best for them. Like the feedback discussion, sometimes they may not be able to articulate what works for them and why, and or what works for them may not even be feasible within the context of your practice. You can again invite them then to articulate what has not worked or any negative learning experiences they remember, and why those methods stick out as being particularly negative for them. What the discussion will do is alert you to any triggers to try and avoid, and if they are unavoidable it also gives you an opportunity to explain why up front to help manage their expectations.
6) Design together where, when and how in-practice teaching will take place. Are you both happy?
7) Pull out a verbal signpost when your are teaching so your learner knows they are receiving in-practice teaching: “I am teaching you now.” Sometimes having a work-related discussion in the tea room at lunch isn’t recognised. We all need to help our registrars to recognise when feedback and teaching is being given.
8) Talk to your registrar about the variety of ways their in-practice teaching requirement will be fulfilled by you and the rest of the team.
9) Start with the RTO requirements. Some RTOs require that one of the three hours typically required for a GPT/ PRRT1 must be quarantined education time and the remaining two hours can be corridor consults, teaching on the run, lunchtime discussions, time with the practice nurse, practice manager, etc. Again you should start with your RTO’s explicit requirements of what the three hours must consist of. A really great RTO will provide a FAQ sheet for both the registrar and the practice on what must be done and what can be done to fulfill the requirement. And this FAQ can then be used during the registrar’s orientation to your practice to ensure both parties are on the same page with regard to their teaching and feedback needs and requirements.
10) Make it explicitly known that in-practice teaching may be clinical or non-clinical in nature and whom in the team is likely to be involved in the delivery of in-practice teaching.
Do I have to pay travel time for a registrar’s educational release?
This is a common question asked by practices. There are a number of factors relevant to working out the answer appropriate to your circumstances. Generally speaking if the registrar is rostered to work and is attending educational release for the full day then their travel to and from educational release would be the same as their travel to and from work – unpaid.
If however a registrar travels to work unpaid, then leaves from work to travel to the educational release location, then this travel time would be paid as part of their normal payment for that day. It would not be paid in addition to their normal paid day, rather it would be part of their usual pay.
What if my registrar works nine-hour days but the educational release is seven hours? Do I pay them for seven or nine hours?
If the educational release were nine hours then you would pay them for nine hours, but in this scenario it is not. You are only required to pay a registrar for educational release they actually attend and only if they would normally be rostered to work then. So should the educational release be seven hours the registrar will need to decide to either reduce their working hours on these days, or in the alternate return to work and complete the additional time (two hours) noting that part of this time will be consumed by travel time between the practice location and the educational release.
Overwhelm is the result of trying to do everything and not playing to your strengths. GP supervisors typically teach, employ, mentor, manage, supervise on top of their own patient load.
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A starker jolt than the New Zealand massacre we will hopefully not experience again. We unreservedly share our sympathies with those directly affected with the loss of loved ones. The tragedy brings into focus the role of tolerance and the need for inclusive diversity.
I read with interest over the past month the MBS review and a range of opinion pieces on how to fix everything that ails primary care.
Of course with an election looming, politicians’ ears will be primed for election promises and poised for damning political assessments of their opponents’ credentials and performance. Given the backdrop of New Zealand and the consequences of divisive, vitriolic discourse I sincerely hope the looming budget and electioneering demonstrates a return to principles that unite rather than divide.
The issues I read across a variety of platforms ranged from a lack of trust, a fragmented industry to competition and a lack of resources. The variety of issues and solutions had me in awe… so many opinions, so many solutions… why so difficult to fix?
As you start to unpick the various issues and solutions you start to see why our bureaucrats and politicians have a hard time landing the ultimate solution. If we cannot articulate and agree on solutions, how on earth can someone outside the profession expect to?
Take the call for a unified approach for example. We would all agree that messages to government are most potent when they are unanimous, such as the call to end the Medicare freeze or the #justagp twitter storm that erupted on the back of the interim MBS review report in 2016. It is clear that we can unite.
The challenge is remaining united when we each have our own particular interests and niche knowledge. Look at the diversity required to feed into the National Rural Generalist Pathway. All participants work in primary care, each with a particular niche piece of the puzzle. We need a variety of stakeholder organisations, both large and small, to provide differing perspectives and be truly representative of our GP members. It’s how we choose to weave the tapestry together that will determine how well the final product looks and suits our profession.
Small organisations exist to fill a critical role. If the need did not exist, nor would the organisations. When I hear about the challenges faced by small business operating within GP training, I observe that small organisations like GPSA with niche focus serve an essential role. When our training practices approach other larger organisations, they might naturally assume they will be supported by them, sometimes to no avail.
The challenge for a consolidated singular bureaucracy is that it takes a long time to move a lumbering ship and be responsive to a massive and diverse membership. Meanwhile a practice, who needed support yesterday is not in a position to wait. Though it is not the intention of large bureaucracies not to assist their members, they can’t be all things to all people, all of the time… and if they tried, they would very quickly find that they were not operating coherently on a rational strategy their members identified with. Enter small niche organisations that are nimble and can serve a specific support role.
In directly supporting training practices and supervisors with often extraordinary circumstances, GPSA understands the degree to which members feel supported no matter how big or small the challenge they face is. That’s not to say GPSA is the only avenue of support available to training practices – we all have a role to play.
We need to be united, where it makes sense. Our diversity makes us stronger when we embrace and harness the roles we each play in delivering the very best for primary care.
We hope the role GPSA plays is important to you as a training practice.
Dr Gerard Connors
Under the NTCER, practices are required to supply a percentage summary at whatever interval has been agreed to in the employment agreement between the registrar and the practice. Importantly, the requirement to provide a summary does not negate a practice’s duty to maintain confidentiality and observe privacy laws.
Imagine you provided an MBS summary to a registrar that was taken and left on a park bench? Who is at fault? The practice or the registrar?
One could argue a clinician has similar privacy constraints that they must operate in as the practice entity itself.
Importantly, in this ficticious scenario, while the document might have been left by an employee and they may well be found to be at fault, the provision of this information in an identifiable format outside of the privacy law constraints remains something for the practice to manage at all times.
As such, while the NTCER requires that payment summaries of percentages be provided to registrars we recommend that you have a look at the format these summaries are provided in.
At the very least payment summaries should follow the following structure:
Your registrar summaries should never contain:
What about item number categories?
You could provide summaries in item number categories, but again you should avoid providing anything in a format that could be easily reconstructed by the registrar to correlate item numbers to patient names.
What training instruction/ policy should be in place regarding privacy?
Your practice will likely have the following in place:
Paid leave attracts the same base rate of remuneration as in ordinary hours.
We recently receieved a query from a practice whose registrar was wondering why they hadn’t seen the 17.5% leave loading they’d expected to see on their payslip.
The registrar was new to general practice and the practice was concerned it had missed something important and wanted to make sure it was doing the right thing.
The question that arose was, have we missed something in the NTCER? Are we doing something wrong? Do we need to be paying a leave loading?
The Answer: no, no and no.
Why the same rate?
The NTCER does not allow for a leave loading. That said you could offer one if you wished, but it is not recommended for the following reasons:
As an employer you need to think about the prevailing conditions that registrars will receive once fellowed. Fellowed GPs tend not to be paid leave at all. Once fellowed, if you want to be able to keep the registrar as distinct from losing them to another practice you might want to think about what scope there is to increase their conditions. If you are already paying leave loadings, a high percentage, etc. then from a business perspective you will likely not be able to offer anything higher and in fact, they are likely to earn less post fellowship – which is ultimately dissatisfying.
Why the confusion?
Registrars, often coming to general practice for the first time, from the acute sector have only experienced working under the medical officers award in their state or territory. Each medical officers award includes a leave loading. This is not inconsistent with other awards your practice would have to observe, such as the prevailing nurses award in your state or territory which attracts similar loadings.
For GP registrars however, once they leave the hospital and are employed by a GP training practice they are no longer employed under the medical officers award. They are employed with common law contracts which simply require that they are paid in accordance with Fair Work Legislation and the NTCER. Neither the NTCER nor Fair Work require the payment of leave loadings.