Monthly Archives: November 2016

Being a mentor and role model – guest post from a supervisor

In a world where the answer to any unticked educational box is an on-line module created by a third party, preferably on a contract, it sometimes seems as if the interpersonal nature of education and training has been lost.

path-upA supervisor whom I have known for twenty years, and who has been a supervisor for thirty years, commented to me that he thought the most important activity of the supervisor is to be a role model.   This is not always spelt out in textbooks, the literature and course curricula.  The emphasis is often on “teaching skills.” Over the years I have heard many GPs spontaneously recall John Vaughan’s influence on their careers whether they encountered him as a student or a registrar.  They have often commented that he takes the trouble to keep in touch with them well beyond their completion of training.  Because I respect him enormously I threw it back to him and asked him to jot down half a dozen points about being a role model. I think these comments also include (conceptually)  aspects of mentoring.  Here they are (grouped in sections):

Ten points of mentoring and role-modelling:

Self awareness

  1. Be aware of being a role model (it happens whatever we do). By this I mean we need to be conscious of our actions at all times, particularly in the presence of registrars and not only in our dealings with them directly but in the way we interact with practice staff and nurses as well as colleagues and contacts beyond the practice environment. Registrars are absorbing much of this behaviour consciously and unconsciously and will model themselves on it or use it as a lesson in how not to behave.
  2. Be willing to accept and acknowledge your own limitations as a doctor and a supervisor

The supervisor’s approach to the registrar (mentor role)

3. Demonstrate interest and get to know the registrar as a person. Without being intrusive, it is so important to learn about and understand the registrar in the context of their world. It is particularly important, for instance, to try and learn where overseas trained doctors have come from and where they wish to take their careers in the future. The other group that comes to mind are those female practitioners who may lack confidence, despite often being outstanding practitioners and whom I have observed, over the last thirty years, to go on to achieve excellent Fellowship exam results.  

4. Encourage registrars, demonstrate confidence in them and take time to support them. It is invaluable.

5. Be sensitive to the registrar’s needs. This moves into a more pastoral role.   Be aware of their moods and state of mind, providing pastoral support when it is needed. Sometimes registrars can become a little lost in the morass of practice and picking up on this and enquiring about their needs and their concerns can be crucial. It is not all about education!

Specific attributes and attitudes that are worth consciously modelling

6. Enthusiasm for general practice – enthusiasm is contagious. By modelling our own enthusiasm for the role of a GP and the privileged entree into people’s personal lives, our registrars develop similar attitudes. The opposite is also true.

7. A positive response in challenging situations – especially when things go a little pear shaped clinically as they sometimes do.

8. A sense of lifelong learning can be promoted. It is not all about the Fellowship exam. Model your own learning for them and demonstrate the fact that you are constantly learning and open to this.

9. Collegiality – with the registrar

  • Acknowledge your own limitations as doctor and supervisor
  • Encourage questioning and accept criticism and constructive suggestions Encourage questioning – especially of you as a supervisor. We are all in this profession together and should not be afraid to accept criticism and constructive suggestions so that it becomes a two-way process.

10. Collegiality – with other doctors and health professionals. Too much of medicine is based on putting our colleagues down instead of understanding where they are coming from. Doing this with our senior colleagues can model behaviour for our registrars.

walking-together  Mentoring can be described as “a personal process that combines role modelling, apprenticeship and nurturing”. The article, True Mentorship in Medicine, describes some qualities of good mentors: “they exude genuine and infectious enthusiasm; they modify their teaching strategies according to learners’ needs; they consistently reflect on their roles; they have excellent interpersonal skills; and they are knowledgeable. These qualities act synergistically to create non-threatening learning environments……..Learning is not about obtaining good evaluations; it is part of the overarching goal of becoming a better physician. The atmosphere generated by a good mentor promotes self-esteem and the importance of lifelong learning…..Mentors, in addition to teaching through words and deeds, show us care and respect and empower us to confidently approach the myriad complications inherent to the human In the end, we must repay our gratitude to our mentors by providing excellent patient care and evolving into effective role models ourselves.”

I think this echoes what John demonstrates and what he has so clearly described above.


Another lengthier and more academic look at the process is found (for those interested) at

Teaching multimorbidity – part three

Practical suggestions

This post follows on from the previous two and focuses more on what supervisors might do (and what has been tried) to help registrars learn, in the practice context, how to manage these particular patients.

Clinical practice

  • Managing multimorbidity requires particular clinical and other skills
  • It is appropriate that trainee GPs acquire these skills – despite other systems being also relevant to care
  • The relevant patient presentation is one with multiple problems (diagnoses / symptoms) and multiple treatments (more complex than chronic disease paradigms)
  • Good care requires being aware of the multiple ways these may interact with each other and how all this impacts on the patient
  • The practitioner needs to be aware how this “burden” may affect effective management

Suggestions from supervisors re teaching multimorbidity

  • Break it down into smaller chunks and teach over the whole term.
  • Use it as an opportunity for a GPMP/TCA in collaboration with the patient to             reveal the patient goals and agenda – which may be different.
  • Demonstrate your own GP Management Plans
  • Check up on social factors and be non-judgmental re non-compliance
  • Suggest tidying the computer record – medications, problem and diagnosis list and teach the use of actions and reminders.
  • Encourage the registrar to speak up as they are viewing the patient with new eyes.
  • Discuss polypharmacy and raise changing medications.

Actions to support teaching in the practice  

We previously developed a practice teaching module with learning objectives which included recognising complex multimorbidity, consulting relevant guidelines, taking a patient-centred approach, utilising appropriate item numbers and consulting with health and other professionals. Tasks included a pre-session activity, case discussion, direct observation of a consultation and follow-up by random case analysis and review of identified learning goals.

jacarandaWe also developed a practice-based, structured assessment tool – one of several Entrustable Professional Activities (EPA) which were discussed in a previous post. It was phrased as: the registrar can be trusted to manage, in the GP context, the ongoing care of an older patient with multiple morbidities and multiple medications (with guidelines on how to assess this).

These two innovations were not able to be adequately implemented (or evaluated) before the government changes to the delivery of GP training but, hopefully, activity will continue in this area and supervisors can take some of these ideas on board.

A suggested approach by registrars to multimorbid patients in practice

  •  Take ownership of the patient
  • Create a Problem list
  • Review the medication list
  • Are there knowledge gaps?
  • Address and negotiate the patient vs doctor perspectives and priorities – do we understand each other?
  • Who is part of the treating team?
  • Preventative health
  • Goal planning
  • Be aware of billing and item numbers
  • Follow up/anticipatory care
  • Use of digital technology

To manage multimorbidity well 

  • You need TIME
  • You need continuity
  • You need patient-centredness
  • You need teamwork, systems etc

To teach and learn effectively about multimorbiditytree-trunk

 We know that learning is more effective if multiple methods are used and if reinforced in different contexts so it is likely that teaching multimorbidity would be best with a multi-pronged approach – given also what registrars find helpful (from surveys & focus groups). This approach ideally would involve workshop teaching, practice teaching, linked formative assessment and self-directed learning.  It should be built on an evidence base of what is effective and it is preferable to research and evaluate what we do as we go.  My preference from previous reading and work in the area is that teaching on the topic should be overtly linked to patient-centredness (rather than just concentrating on multiple chronic disease guidelines). A conceptual framework can be helpful. 

Foundation to build on 

Registrars potentially see sufficient patients with multimorbidity. When given a choice, registrars describe multimorbid patients as “challenging” or “interesting” rather than difficult or frustrating so this is encouraging. They reported, mostly, being able to have long enough consultations (less so in Term 3) and to organise follow up consultations.  Focussed workshops are useful and there is concensus that specific  experiences (hospital terms for instance) and teaching methods are helpful in developing their skills.  Resources and development for supervisors could enhance the practice experience.

Still a way to go and future challenges

These previous pilots of multimorbidity teaching demonstrate some increased confidence but could we do better? The challenges noted included the difficulty of implementing multidisciplinary care in general practice and initiating changes to medications – all very practical issues.

The standard definitions of multimorbidity (2 or more, or 3 or more comorbidities) include a range of multimorbidities which are not always too challenging and may have minimal impact on the patient. However, there has been more recent discussion of complex multimorbidity – sometimes defined as problems in two or more systems or multiple morbidities combined with psycho-social problems.  These are much more challenging. Hard to treat musculoskeletal and pain problems are also common comorbidities with other conditions.  Multimorbidities begin earlier and are more prevalent in areas of socio-economic deprivation and patients with such demographics often have less access to services.

rock-patternIf management is challenging then so is teaching about it – and so is measuring the effectiveness of that teaching.

“Complex multimorbidity” is where the focus needs to be in the future – the next challenge.


Teaching Multimorbidity – part two

Just an initial parenthesis about multimorbidity

If you ever wondered about the importance of multimorbidity, then wonder no more. Late yesterday (a Friday) the Australian government announced a summary of its revamp of funding policies and parameters for the “Health Care Home”.  These apply to general practice and refer to patients variously described as having chronic diseases and complex chronic illness – in short, it includes multimorbidity.  There are many really interesting articles and studies out there raising complex aspects of how to define, classify and research (and hence add to the evidence base of) multimorbidity, but from now on it will probably also be defined and counted by the Department of Health.  If you were wondering which patients we are generally talking about in referring to multimorbid patients, it is interesting to dip into a couple of articles. An interesting one in the Australian context is Brett T et al. Multimorbidity in patients attending 2 Australian primary care practices. Ann Fam Med 2013; 11(6): 535-542. In general practice, maybe a third of patients will have some sort of multimorbidity (defined as 3 or more co-morbidities) and more than half of these will not be elderly, but the clinical significance will also depend on severity and multimorbidity is more common in deprived populations. The estimated proportion of these patients will also depend on the classification system – eg whether cardiovascular is a category or individual diagnoses such as IHD or AF are listed and whether risk factors such as hyperlipidaemia are included. As Einstein said, “Not everything that can be counted counts, and not everything that counts can be counted.” Well, I guess it can but how meaningful it is may be in dispute.

pasha-bulkaGovernments have persuaded us of the impending doom to the health system and solutions are proposed. The Health Care Home (if implemented, not just piloted) will affect the way we fund (and manage) the majority of consultations in general practice, if not the majority of patients (given that these patients, unsurprisingly, attend more frequently).  This will affect the way that we teach about the management of multimorbidity in the future but it will still be important to understand the experience of the patient, the clinical issues regarding effective treatment and the challenges faced by health professionals. This is an interesting summary of the latter point: Sinnott C et al doi:  10.1136/bmjopen-2013-003610 GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Registrars confidence levels – 2014 snapshot

As part of routine feedback, evaluation and quality improvement in training, a survey was done in 2014 which was a snapshot of confidence levels across registrar terms and in different curriculum areas. Basically, registrars appear to increase in confidence in all areas by term 3 (over 18 months), as might be expected.  On a scale of 1-5 the average difference in confidence levels, between Term 1 and Term 3, in managing various patient groups and problems was 0.6 (from 3.3 to 3.6).  However there was quite a range – from 0.3 to 0.9.  The areas rating 4 or above in levels of confidence by Term 3 were:

  • uncomplicated older patients (also high initially)
  • young children with acute presentations
  • patients with hypertension, hyperlipidaemia, diabetes
  • women’s health problems.

Of course, this could reflect a high initial level of confidence, effective teaching or natural improvement with appropriate experiences. It would be nice to have the opportunity to tease this apart.  In our then Regional Training Provider there was a significant focus on education in cardiac risk factors and diabetes and numerous sessions on women’s health and mental health.

Interestingly, therefore, the lowest Term 3 level of confidence was with multimorbid patients (with three or more chronic diseases / morbidities). The difference in confidence between Term 1 and Term 3 in this area was relatively small and from a low base. There had been no focussed specific input except that some of the registrars may have heard a one-off lecture by a visiting international speaker.  Interestingly, also, the broadest range of confidence levels (averages don’t always tell the whole story) were in child health, women’s health and multimorbidity (2-5) so perhaps not everyone needs the same interventions in each area and learning needs to be individualised, as we know.

After the implementation of the new multimorbidity education approach in late Term 1, the confidence levels were followed in this cohort. They already demonstrated a relatively high confidence with uncomplicated older patients despite educator concerns about lack of clinical exposure.  Multimorbidity started at a low base and then increased by 0.6 which was just below the average increase in confidence over the period.  We asked a new question in the final round about confidence levels in “patients with multiple morbidities PLUS polypharmacy or psychosocial problems”.  This only achieved a level of 3.3 (the lowest in term 3).

I suspect that “complex mutimorbidity” is the new frontier.

What registrars see

Registrars felt that they were seeing sufficient multimorbid patients for learning. In end-of-term feedback on their perceptions of the variety of patients in their placements, registrars (on average) reported seeing a good proportion of children, older patients, chronic disease and multimorbidity along with only slightly less mental health and women’s health.  On the other hand many registrars had limited experience in men’s health, palliative care and nursing home visits.  However, numbers and statistics do not always reveal the full picture.

In the practice

A registrar may see more than the average number of older patients or chronic disease diagnoses and yet they may be having shorter consultations with low markers of continupaperbark-fernleighity and unexpectedly lower than average number of problems per consult. It’s good if a training program collects, utilises and feeds back this sort of data in order to close the educational loop. This type of picture may possibly be interpreted as less engagement with the complexity.  On the other hand a registrar seeing fewer such patients may be encouraged by their supervisor to gain the maximal learning from their experiences. The potential is there but there needs to be an individualised approach – the experience for each registrar in each practice can be widely different at different points in training and a supervisor can adjust their teaching in the light of this.

What is helpful – the registrars’ retrospective view

A summary of points from previous survey and focus group data

  • It is useful to experience the continuity of staying in the same practice for more than six months.
  • Initially consultations tend to be “repeat script” appointments but by Term 3 they were taking more ownership.
  • This was affected by how much supervisors “owned” their own patients.
  • It was limited also by the variability of supervisor’s expertise in the area
  • The top three useful strategies were: 1. case discussion 2. prior hospital experience (gen med, aged care, pall care and ED terms) and 3. workshop sessions.

Registrar suggestions to maximise effective learning in this area

  •  Learning needs to be patient-based in the practice and involve case review with the supervisor (with the patient if needed) plus discussion of common combinations of co-morbidities.
  • There is a preference for case-based teaching in workshops.
  • Medication review discussions should happen with supervisors.
  • Early exposure to guidelines and read up when not confident.
  • “Co-ownership” of a chronic disease patient with the supervisor.
  • Involvement in nursing home care
  • Emphasis on information re local resources