Configurations for obtaining in-consultation assistance from supervisors in general practice training, and patient-related barriers to trainee help-seeking: a survey study.

BACKGROUND: General practice (GP) trainees may seek supervisor assistance to complete their patient consultations. This in-consultation assistance plays a key role in the supervisory oversight of trainees and in trainee learning. It may be obtained face-to-face, or using phone or messaging systems, and either in front of patients or outside their hearing. Trainee concerns about decreased patient impressions of their competence, and discomfort presenting patients within their hearing, act as barriers to seeking help during consultations. Little is known about the frequency and associations of trainee concerns about these patient-related barriers, or the various trainee-supervisor-patient configurations used to obtain in-consultation assistance. METHODS: Australian GP trainees rated their frequency of use of five specific configurations for obtaining in-consultation assistance, perceived change in patient impressions of their competence after this assistance, and relative trainee comfort presenting patients outside, compared to within, patients' hearing. Statistical analyses included descriptive statistics and multivariable logistic regression. RESULTS: Responses were received from 778 Australian GP trainees (response rate 89%). Help-seeking configurations did not differ between trainees at different training stages, except for greater use of electronic messaging in later stages. In-consultation assistance was most commonly provided by phone between trainee and supervisor consulting rooms, or outside the trainee's patient's hearing. Supervisor assistance in the trainee's room face-to-face with the patient was reported as either never or rarely obtained by 12% of respondents. More trainees (25%) perceived that patient impressions of their competence increased after help-seeking than perceived that these impressions decreased (19%). Most trainees (55%) preferred to present patients outside their hearing. Trainee age was the only variable associated with both patient-related barriers. CONCLUSION: Supervisors appear to have considerable influence over trainee help-seeking, including which configurations are used and trainee perceptions of patient-related barriers. In-consultation supervision may actually increase trainee perceptions of patient impressions of their competence. Many supervisors and trainees may benefit from additional educational and workplace interventions to facilitate comfortable and effective trainee help-seeking in front of patients. More work is required to understand the clinical and educational implications of different help-seeking configurations when trainees require 'just in time' supervisor assistance.

Ethics and professionalism in general practice placements: what should students learn?

BACKGROUND: A diverse range of ethical and professionalism issues has been identified in Australian general practice. OBJECTIVE: To establish which of these issues general practitioner (GP) teachers and students consider the most important, to enable GP teachers to facilitate student learning in this domain. METHODS: A survey instrument was developed and distributed to GP teachers and medical students. Participants rated the importance of students learning about each of 32 different ethical issues. Students rated their confidence in managing these areas. RESULTS: GP teachers and students agreed on many of the most important issues (including patient confidentiality, medical mistakes, working with colleagues and drug-seeking patients); there are also some interesting differences. Student confidence in patient confidentiality was very high, but particularly low in career and training decisions and medical mistakes. DISCUSSION: Students want to learn more about career and training decisions and medical mistakes. They may underestimate the complexity of confidentiality and professional relationships in general practice.

How confident are general practitioners in teaching medical students about ethical issues on general practice placements?

BACKGROUND: Despite a paucity of evidence to guide teaching about medical professionalism and ethical issues, there is a widespread consensus that medical students should learn about these issues on clinical placements. Exploring the confidence of general practitioners (GPs) in teaching various topics will identify areas for further discussion, support and/or training. METHODS: A survey was developed and distributed to 65 teaching practices. Thirty-seven GPs responded by rating their confidence in teaching about 32 different ethical issues. RESULTS: Overall, GPs were confident in teaching about these issues. Confidence was lowest for doctors' social and political responsibilities; ethical lapses in colleagues; impairment in colleagues; cross-cultural issues; and moral motivation, judgement, courage and sensitivity. DISCUSSION: Further training for GP teachers may be particularly useful in the important areas of impairment and lapses in colleagues, and cross-cultural issues. Uncertainty about the scope of doctors' social and political responsibilities may limit GP confidence in teaching in these areas.

The informal curriculum - general practitioner perceptions of ethics in clinical practice.

BACKGROUND: Australian medical students should graduate with an understanding of the principles of medical law and ethics, and their application to clinical settings. Although student perspectives have been studied previously, the teacher experience of ethical issues also needs to be understood, particularly in the general practice setting. METHODS: Interviews were conducted with a convenience sample of 13 general practitioner teachers. They were asked to reflect on common and/or important ethical issues in their day-to-day practice. An inductive thematic analysis of the data was performed by two investigators, who reached a consensus on major themes using an iterative, dialogic process. RESULTS: Participants reported negotiating ethical issues frequently. Major themes included patient-doctor relationships, professional differences, truth-telling, ethically 'grey' areas and the personal demands of ethical decision making. DISCUSSION: General practitioners in this study describe sometimes needing to apply judgement and compromise in situations involving legal or ethical issues, in order to act in the best interests of patients and to successfully negotiate the patient-doctor relationship. Students learning in this clinical context may perceive mixed messages and ethical lapses in these challenging 'grey' areas. The ethical acumen and emotional resilience of both students and clinical teachers may be enhanced by ongoing reflective discussion with colleagues.