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.
After hours /work outside of ordinary hours attracts the same base rate of remuneration as in ordinary hours.
We recently received a query from a practice whose registrar was adamant that they should be paid double time on a Sunday.
The registrar wanted to work Sundays, because it suited their personal circumstances and having the registrar available then to patients also worked for the practice.
The question that arose was, have we missed something in the NTCER? Are we doing something wrong?
The Answer: no
Why the same rate?
Because the NTCER is built around the prevailing conditions that registrars will receive once fellowed. Fellowed GPs don’t get paid more (by the practice) the minute the clock hits 8.01pm. A GP registrar receives what the prevailing market allows to fellow GPs. If there is a higher MBS rate available after hours then a registrar will receive greater reward for the item number after hours. If there is not a higher reward then they will not – nor will their fellowed GP counterparts.
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 loading for after hours and weekends. 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 an after-hours loading.
What if my registrar is working a 38-hour week and then working additional hours?
If the work outside of ordinary hours is on top of their 38-hour week on a regular basis, anything above 38 hours (averaged over 4 weeks) attracts either Time Off In Lieu (TOIL) or can be paid by the practice at 150% of the base rate with no time off.
Is it the practice’s prerogative whether we provide time in lieu or additional payment?
Yes. You should consider the business needs and overheads that will need to be serviced by whatever decision you make. I.e. if you need the clinicians on the ground such that it is more advantageous to pay the additional loading you can make that decision. If you don’t want the additional overheads and you have enough clinicians to service demand then you may prefer to provide a TOIL day. In which case, it then becomes the prerogative of the registrar as to when they take that TOIL – though when and how must be consistent with your practice’s leave policies.
What are Australian Immunisation Register (AIR) payments
Immunisations and the associated actions attract an Australian Immunisation Register (AIR) payment, which falls under the Service Incentive Payment (SIP) Scheme – Service Incentive Payments (SIPs) are made to General Practitioners who work with a practice that is enrolled in the Practice Incentives Program (PIP).
Should AIR payments relating to work completed by registrars be paid directly to registrars?
No. SIPs (including AIR payments) should be treated like all other MBS income generated by the registrar. Paid to the practice, then distributed to the registrar as part of their percentage calculation.
Is there any risk in paying all of it to the registrar directly?
Yes. As part of the percentage calculation (at whatever percentage and interval you agreed to in your contract with the registrar) the payments also attract superannuation. If you pay the full amount directly to the registrar, you could be liable for superannuation on top of the AIR payment if it is not managed appropriately, even where you have paid the full payment to the registrar directly. It therefore becomes a risk to have the full amount paid directly to the registrar and you could end up paying more then you receive.
It is therefore, much safer from a superannuation guarantee compliance perspective to treat your SIP payments like the rest of percentage payments and include them in the percentage calculation interval, which then ensures the correct amount of superannuation is also paid at that time of dispersement.
Who should receive the AIR payments?
When a practice manager is filling out the AIR paperwork for SIP, they should provide the practice’s bank details for the deposit.
What percentage of the AIR payment should be paid to the registrar and when?
Whatever you have agreed to in the registrar’s employment agreement, but not less than every 13 weeks. GPSA recommends that practices pay the NTCER rate of 44.79% to the registrar at intervals of no more/ less often than every 13 weeks.
Do the AIR payments attract super?
Yes. As described, where it is managed as a part of the percentage calculation, it also then attracts superannuation when paid as a top-up at whatever interval you have agreed to.
As we move into a new training year you will be farewelling your current registrar and welcoming the new one. Some registrars will be staying on as Fellows to become a permanent part of the practice team and hopefully one day a Supervisor. So, the cycle of learning, consolidation and eventually teaching and supervision goes on.
If this is your first registrar as a new practice it is important to ensure your registrar has a good orientation. To do this you need a plan and a good plan always starts with a checklist. GPSA’s orientation checklist and New Supervisor guide are a very useful place to start.
I strongly advise new Supervisors to look at the GPSA guides and other educational resources on the GPSA website. For those Supervisors/Practices who have been hosting registrars for a few years and are looking to take their supervision to a higher level I recommend “Best practice for Supervision in General Practice.”
Practice managers will also find useful information in the Guides. As a practice member you also have access to a contract template to use with your registrar.
Your regional training organisation (RTO) will also have resources that can guide you in teaching and supervising your registrar, these are essential reading. Your RTO provides Professional development (PD) for Supervisors. These PD activities not only enhance your skills and knowledge, but are valuable networking opportunities with other Supervisors. Many friendships have been formed through these forums.
With the severe drought in parts of Australia and current water crisis in the Murray Darling basin I note the recent EAT-Lancet commission report titled “Food in the Anthropocene” has devised the world’s first scientific targets for a universal “healthy planetary diet”.
They note that obesity, undernutrition and climate change are the worlds biggest threats.
I shall be carefully reading this report and discussing it with my registrar and I encourage you to also.
Finally a warm congratulations to those GP Supervisor members who received Order of Australia honours last week
On a personal note I would like to congratulate my sister Dr Christine Connors, General Manager Primary Healthcare Top End (Public health physician) who was awarded an OAM on Australia Day for services to medicine in a range of roles. Christine has been a tireless campaigner for Aboriginal health for many years.