With a grain of salt? Supervisor credibility and other factors influencing trainee decisions to seek in-consultation assistance: a focus group study of Australian general practice trainees

Abstract

Background: 'Ad hoc' help-seeking by trainees from their supervisors during trainee consultations is important for patient safety, and trainee professional development. We explored trainee objectives and activities in seeking supervisor assistance, and trainee perceptions of the outcomes of this help-seeking (including the utility of supervisor responses). Methods: Focus groups with Australian general practice trainees were undertaken. All data was audio-recorded and transcribed, coded using in-vivo and descriptive codes, and analysed by the constant comparison of provisional interpretations and themes with the data. Findings are reported under the over-arching categories of help-seeking objectives, activities and outcomes. Results: Early in their general practice placements trainees needed information about practice facilities, and the "complex maze" of local patient resources and referral preferences: some clinical presentations were also unfamiliar, and many trainees were unaccustomed to making patient management decisions. Subsequent help-seeking was often characterised informally as "having a chat" or "getting a second opinion" so as not to "miss anything" when trainees were "not 100% sure". Trainees emphasised the importance of being (and demonstrating that they were) clinically safe. Workflow constraints, and supervisory and doctor-patient relationships, had a powerful influence on trainee help-seeking activities. An etiquette for providing help in front of patients was described. Trainees assessed the credibility of supervisors based on their approach to risk and their clinical expertise in the relevant area. Several trainees reported reservations about their supervisor's advice on occasions. Conclusion: A trainee's subsequent help-seeking is strongly influenced by how their supervisor responds when their help is sought. Trainees prefer to seek help from credible supervisors who respond promptly and maintain trainee 'face' in front of patients. Trainees learn through help-seeking to make their own clinical decisions but may remain uncertain about professional and societal expectations, and curious about how other general practitioners practise. Trainees value opportunities throughout their training to observe expert general practice.

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

“…Supervisors were more likely to complete their own consultations, than to interrupt these, before providing in-consultation face-to-face assistance. This is likely to prolong the trainee's consultation and delay their subsequent consultations, which has been identi ed by trainees as a barrier to help-seeking (13). Patientcentred supervisor strategies to safely interrupt and resume their own consultations should be identi ed.…”

“…Assistance which is obtained in front of patients, for example, calls on the trainee to present the case within the patient's hearing, and both trainee and supervisor need to manage patient impressions of the trainee's competence skilfully in order to avoid the trainee losing face and the patient losing con dence in the trainee. Trainee discomfort presenting in front of patients, and trainee beliefs that patient impressions of their competence decrease when they obtain in-consultation assistance, have been reported in the literature (13). These are likely to be barriers (referred to in this paper as "patientrelated barriers") to trainees seeking this assistance.…”

“…There are different trainee-supervisor-patient con gurations for obtaining this in-consultation assistance: it may be obtained either within or outside the patient's hearing, and either face-to-face, by phone or using internal messaging (12,13). Different con gurations may have different implications for trainee learning (12) and patient safety (14).…”

“…These are likely to be barriers (referred to in this paper as "patientrelated barriers") to trainees seeking this assistance. Conducting patient-centred consultations, and maintaining patient con dence in their clinical competence, are important considerations for GP trainees (13,17). Trainees in hospital contexts use various strategies to present patients to senior doctors, using medically sanctioned talk to indicate areas of uncertainty (18,19) which preserves peer and supervisor impression of trainee competence.…”

“…These strategies may include casting doubt on the reliability of patient histories (18), which may be less acceptable in front of general practice patients, adding to the challenges of in-consultation help-seeking for GP trainees. In order to circumvent the risk of decreased patient or supervisor impressions of their competence, and/or reducing the patient-centredness of their consultations, trainees may leave the patient to seek in-consultation assistance, or defer their helpseeking until the patient has left (13). It is therefore important to identify the extent of patient-related barriers, as a rst step in supporting trainees to obtain appropriate in-consultation assistance.…”