Observational Feedback as a Supervisor’s Tool

Is it JUST for the struggling registrar ?

Learning Objectives

• 1. Develop an improved understanding of the role of observational feedback as a routine Supervision activity

• 2. Practise delivering feedback to Registrars with different learning needs

• 3. Share and workshop experiences of enabling “one a week” to occur in your individual clinic setting

What Are We Looking For ?

• Introduction• Doctor : patient relationship• Communication skills• History taking, reasons for attendance• Physical examination• Problem definition, preventive health• Explanation & management• Conclusion, safety netting• Time management• Record keeping

• https://www.youtube.com/watch?v=noMfGDTIKNU

Learning Objectives

• 1. Develop an improved understanding of the role of observational feedback as a routine Supervision activity

• 2. Practise delivering feedback to Registrars with different learning needs

• 3. Share and workshop experiences of enabling “one a week” to occur in your individual clinic setting

• Ruth / Rick is a shy GPT2. (S)he is on Remediation due to borderline results of clinical assessments in the last Term. You have been briefed by her / his Training Advisor who has told you to “keep a close eye”, as (s)he takes forever to get things done and “really needs to be pushed”. In a recent clinical encounter you notice (s)he has taken over an hour to take a history on Mrs Gurramurra, a patient with asthma and yesterday her / his case presentation was very long and tedious.

• Kim is aged 35, married with 2 children. She is early in her GPT1 term in an Indigenous Health Training Post. She graduated from a Chinese University and soon after emigrated to Australia. She had a reasonable range of experience here initially, then took several years off to have her children. She has been doing mainly Emergency jobs in the last two years. She is quiet and reserved and she has a strong accent. The staff report that she is very polite and willing. Patients seem to like and respect her but often seem unsure about what they are expected to do. Older patients especially say they have difficulty understanding her. In your teaching sessions you have found large gaps in her medical knowledge and the feedback from NTGPE’s pre assessment confirms this.

• Jason / Jade is a PRRT1 in a small town hospital. (S)he has been under your supervision in the emergency department for over 2 weeks. Your impression of Jason / Jade is that (s)he is knowledgeable and highly competent in his / her clinical practice. (S)he also appears to be extremely confident in tackling anything new. Some of the staff think ‘Jase’ / ‘J’ is a great bloke / gal to have around as (s)he is so capable of doing anything asked of him / her. (S)he even likes to have a bit of a joke around in the tea room which lightens up the mood in an otherwise busy and stressful ED. Other staff have voiced some concerns about his / her bedside manner saying that (s)he often fails to introduce him/herself to patients, has been observed speaking abruptly to them and treats some of the nursing staff in a condescending manner. On one occasion you overhear an interaction between Jason / Jade and a patient with a mental health problem. Jason / Jade’s manner is aggressive towards the patient and (s)he appears to be annoyed at the behaviour the patient is exhibiting. You notice Jason / Jade walk away and joke with a nursing student about the mental state of the patient.

• Daniel(le) is repeating his / her PRRT4 due to unsuccessful completion in the previous Term. He passed his / her exams and tasks but must now pass all clinical requirements. (S)he arrives at his / her community based placement displaying a demeanour of boredom and disinterest. You ask Daniel(le) for his / her Learning Plan and (s)he gives you last year’s version with ‘bits’ missing and you note (s)he has left his / her stethoscope at home. You ask him / her to assess a patient for discharge. (S)he declines on the basis that (s)he has already done this sort of thing before on his / her last clinical placement. (S)he asks you for something more interesting to do.

• Chris is a GP Registrar in a Military Medicine ESP Term. Chris’s philosophy has always been to ‘take the easiest road’. You are his / her clinical supervisor and on meeting him / her you notice this laid back attitude such as often arriving late for clinical tutorials or leaving early. You also notice that (s)he has a very casual manner with patients. During feedback Chris comments that (s)he has been told before that (s)he is too casual, but believes that his / her style of interaction is important in establishing rapport with ADF patients. As the clinical teacher, alarm bells start ringing when you see the following on a patient ward chart :

• Chris’s findings – afebrile, sinus rhythm, BP 120/80• Real findings – temp 39, atrial fibrillation, BP 90/60

• Maria is a 44 yo IMG who originally came from the Philippines where she had been a cardiologist in a large hospital. She is in the first few weeks of her GPT2 term doing RACGP pathway under the AGPT. The practice staff report she is rather aloof and can be quite demanding. Several patients have complained that she seems more interested in the computer and in their investigation results than in them as people. In the few teaching sessions you have had she seems very knowledgeable about most areas of clinical practice and has corrected you on a few occasions! She gets through the work well and her medical records are excellent. She has firmly resisted your request to sit in on her consultations.

• Ali is from Iraq. His English is good. He is married to an Australian. He has had limited hospital experience. He is in the middle of GPT1 at a mainstream general practice. He gets on well with practice staff and there have been no adverse reports from patients. He seems to have a reasonable grasp of clinical medicine but admits he cannot understand why so many patients come with minor complaints. He feels embarrassed when they introduce personal matters into the consultation and feels that this is not appropriate to be dealt with by a doctor. He has little idea about community resources and relies a lot on making referrals to the local hospital and on phoning hospital colleagues for advice.

Slow Learner

• Be explicit about time frames. • Consider providing more time to meet objectives and

provide extra learning sessions. • Allow more time to practise and offer extra encouragement • Concrete examples of time management• Address knowledge / skills deficits• Encouragement and exploration of fear of failure• Provide safe ‘risk taking’ opportunities• Address language barriers with strategies specific to those

from NESBs

Unmotivated Learner

• Discuss the learner’s professional responsibility to their patients, supervisor and practice.

• Highlight the learner’s responsibility to meet training objectives. • Relevant learning opportunities ?• Bridging theory-to-practice gap ?• Appropriate determination of learning needs at outset ?• Explore other issues that may be leading to lack of motivation:

– Long term – is becoming a GP right for them? – Acute – are there any other issues at play? – Subject matter – is this an area that is just not of interest to them?

Incompetent Learner

• Initial determination of learning needs• Offer self-directed learning projects. For example, ask them

to look up a condition and complete a presentation. • Focused, structured teaching• Provide a safe environment. Where possible, offer the

learner an opportunity to practise on supervisor or a practice staff member first; or in a simulation setting.

• Critical incident debrief ( & defuse )• Internal & external drivers ?• Counselling ?• Reporting ?

Poorly Interacting Learner

• Insight ?• Learner aware of your view as supervisor ?• Clear standards of acceptable behaviour ?• Need time set aside to address concerns and

implement a plan

MONITOR

LIAISE

AND PLEASE, PLEASE

DOCUMENT !!