To aid data interpretation responses were described as follows: one to six participants as ‘few’, seven to 12 as ‘some’, 13–18 as ‘many’ and 19–25 as ‘most’. Key themes identified included supervision participation related to quality of clinical care, busy-ness of the practice, patient access and energising rural GPs. The final theme, concerning business factors, was the strongest.
- Characteristics of the sample and supervision participation
Thirty-one GPs indicated their interest in participating in the study, of whom 25 GPs were interviewed. Of the GPs not interviewed, one was away travelling, one did not meet the eligibility criteria, and remaining interested GPs were not eligible due to capped funding for the vouchers. Table 1 describes the participating GPs’ characteristics.
[Table 1 here]
All participants except one were either currently supervising in some manner, or wanted to return to or take up supervision if the conditions were right. The one participant who did not want to supervise was an overseas trained doctor, and did not feel confident enough at this point in their career to take up supervision. The concern was mainly due to knowledge of Australian training and role as a parent, but it was conceded that this would likely change over time.
Most (19) GPs in these rural Tasmanian communities perceived that registrars positively impact the quality of care, both directly: “they usually really want to do a good job and so I think that elevates the standard of care” (#12, >5 FTE, outer regional), and indirectly through their impact on supervisors and on other practice staff: “It makes you stay up to date; it makes you think about your own practice, it makes me safer, in clinical reasoning and so forth” (#15, <5 FTE, outer regional). Another participant noted a registrar who was “extremely competent” so “we were sometimes able to ask him [the registrar] about things that we really weren’t certain about” (#17, >5 FTE, inner regional). The presence of registrars was noted to be “a positive experience for the whole practice not just the other doctors… I think that everybody learns from having a registrar there.” (#16, <5 FTE, outer regional).
Along with new evidence-based practice, registrars also bring their modern learning styles and technology skills which can benefit the practice: “if I want to explain something about a toe, you know, straightaway we’ve got a 3D image” (#13, <5 FTE, outer regional). A few participants also noted that registrars can provide opportunities for self-reflection. One participant explained “you … have the ability to reflect upon your own consulting style … when you’re looking closely at someone else’s” (#11,<5 FTE, outer regional area) and another noted “If you’re critiquing… how other people are doing stuff, you’re also critiquing and analysing how you do stuff” (#13, <5 FTE, inner regional).
Some (7) participants also commented that in addition to the benefit of extra consulting capacity, registrars can directly benefit patients. One noted “as far as the patients are concerned… they love them and they’re always heart broken when they leave” (#15, <5 FTE, outer regional). Patient-specific benefits included registrars providing more choice so that patients could see a different doctor if they did not like the other doctors, extra capacity so patients have improved access, that registrars have more time to spend with patients and listen to them, and that seeing a registrar can provide a greater sense of anonymity if patients want to talk about an issue with a doctor they do not already know through other community interactions (e.g. school or sports).
Yet not all registrars bring these benefits. A few (6) participants, across a variety of practice sizes and locations, talked about the challenges of supporting, and working with, a registrar, when the registrars were impacting negatively on quality of care:
it was difficult because we had patients complaining about him… I saw him hurt one patient just using an auriscope and gouging the inside of a guy’s ear by sticking the thing in his ear with poor technique even though I’d taught him the correct technique” (#,1, >5 FTE, inner regional area).
A few others (5) discussed a mismatch between the registrars’ and the practices’ expectations, style of work, location, or culture, such as “it’s far too hard to work, to see 10 patients a day” (#6, <5 FTE, remote area), and “we work very much on a team model and registrars that don’t work to that kind of mentality—we’ve had a few that haven’t lasted” (#5, >5 FTE, outer regional area).
- Busy-ness: help or hinder?
Many (17) of the GPs in these rural communities talked about access issues related to how busy their practices were, describing them as: “very busy clinic… [the] doctors who work in our practice … work pretty hard” (#1, >5 FTE, inner regional area), “…just too busy” (#2, >5 FTE, outer regional area), and “it’s pretty small, but very, very busy” (#11, <5 FTE, outer regional area). The impact of taking on a registrar was perceived in two divergent ways—for some practices a registrar could help alleviate the busy-ness, but for other practices taking on a registrar added to the busy-ness. For example, supervising registrars could provide extra workforce capacity, benefitting GPs and their patients with “an extra pair of hands” which assisted in different ways: “getting home at six-thirty instead of eight o’clock” (#1, >5 FTE, inner regional area), or providing “the chance to have people come in on the day, otherwise … I am booked out for about four weeks in advance” (#24, >5 FTE, outer regional).
Conversely, trying to support registrars when so busy can mean it is challenging to “juggle the schedule” (#12, >5 FTE, outer regional). Practice size was a key influence on the ease or difficulty of supervising registrars while maintaining patient access to care. A few (5) participants noted that registrar supervision could be particularly difficult for smaller practices compared to larger practices. For example, managing the teaching load could be difficult compared to larger practices which have more GPs where they can “share the load (#2, >5 FTE, outer regional). One participant explained:
It might be alright in a bigger practice where you can share it around, and do a bit here and a bit there, but … for me to set aside three hours a week, for a basic registrar, is just crazy (#11, <5 FTE, outer regional area).
Other responsibilities that rural GPs carry, such as servicing the local hospital, can similarly impact on the ability to take on registrars by making potential supervisors feel “stretched too thinly” (#17, >5 FTE, inner regional).
An additional benefit to practices was that the registrar may stay beyond the training, improving patient access in the medium and longer term: “we got her in about 2010, I think, so she went through, got her fellowship, she then stayed with us for another… four to five years” (#11, <5 FTE, outer regional area). Many (14) participants undertook supervision in the hope of securing a doctor to support their succession planning, but there were few instances where this directly occurred. One participant, considering the seemingly insurmountable difficulties of recruiting doctors to remote Tasmania, reflected “you can’t conscript … I’d like to, but [we’re] not allowed to” (#6, <5 FTE, remote).
A further issue related to access was what happened when the supply of registrars was inconsistent. Some GPs noted that when a registrar leaves the extra work done by the registrar falls “back on the existing doctors … to see all these additional patients” (#16, <5 FTE, outer regional) and “the registrar leaves and then all of a sudden we’ve got more patients than we know what to do with again” (#,1, >5 FTE, inner regional area). The “downside of having intermittent registrars” (#1, >5 FTE, inner regional area) and the need for an ongoing flow of registrars for consistent provision of GP services in rural towns was further highlighted: “If you were able to guarantee a practice registrars that would… make a massive difference … then you know you can build up your practice [take on new patients] because you’ve got enough doctors” (#15, <5 FTE, outer regional).
Participants found supervision activities were enjoyable and supported them to better address community needs. Registrars could also influence a practice through their “youthful energy in the practice” (#12, >5 FTE, outer regional). One participant reflected that “they’ve got a bit more energy and a bit more enthusiasm… rural doctors, can get crusty and grumpy; it protects you from that a little bit too” (#15, <5 FTE, outer regional).
Many (15) participants who currently or had previously supervised noted the professional enjoyment and satisfaction they gained from registrar supervision, such as the “fulfilment of knowing that you’re helping with a new generation of doctors” (#13, <5 FTE< outer regional) and “watching them grow… it’s a satisfying job” (#16, <5 FTE, outer regional). The enjoyment of teaching was also a particular benefit for some (8). Participants also noted increased personal satisfaction and developing new friendships as rewards for supervising; that “it’s just nice seeing new and different people all the time” (#15, <5 FTE, outer regional), and that it can be “a lot of fun” (#24, >5 FTE, outer regional).
GPs initially trained outside of Australia expressed some specific difficulties. One overseas trained GP, who indicated that they did not want to become a supervisor, could still identify positive experiences of their informal co-supervision:
when I was starting here, I’d be very hesitant to answer a registrar’s question, but now …I’ve been here four years, so when they ask me a question they’re similar to the patients I’ve seen before … I find it very fulfilling because you’re able to help someone and pass on your experience to them (#12, >5 FTE, outer regional).
Another participant, who was also an overseas trained doctor and who had previously provided co-supervision, believed their background could support other similar doctors who were undertaking registrar training in Australia: “Australian graduates…will never be able to relate to what somebody who’s coming from outside has experienced, so that’s the one reason that I want to be involved - in making their path a little easier” (#5, >5 FTE, inner regional).
But for some overseas trained doctors, a lack of confidence may limit their participation in registrar supervision: “my practice principal talked to me about ‘would you like to supervise a registrar’ and I told him I am not confident - I don’t think I can do it” (#21, >5 FTE, outer regional).
Key to any supervision in the rural context studied, was having a sustainable business model to support it and actually having registrars allocated to a practice.
Concerns around the financial aspects of supervision were common as participants noted supervision “eats in on their ability to earn” (#25, <5 FTE, outer regional), and “there’s no financial incentive really because registrars and first year registrars don’t tend to make any money for the practice (#2, >5 FTE, outer regional). One participant, who had never supervised, but had wanted to and investigated it, explained that:
we decided that having a GP registrar was not going to be cost effective… GP registrars are employees so … if a GP registrar was unwell and could not work suddenly, I would still have to bring in an income to cover that registrar’s leave (#10, < 5 FTE, inner regional).
For this participant to start supervising it would be an “issue of getting the financials right”.
The challenges of bringing in income when being part-time can also impact on intention to supervise or not: “because I’m only working part-time, from a financial point of view it’s also difficult because … I need to see patients to make money and … supervising a registrar slows that down a little bit” (#16, <5 FTE, outer regional).
Stage of career may be another influence on how important the business aspects of supervision are, with one participant in the later stage of their career seeming less concerned by this despite acknowledging the poor remuneration: “you do get paid a little bit but you know it certainly doesn’t make up for cutting back on how many patients we see, but to me that’s not, at this stage, all that important” (#12, >5 FTE, outer regional). Stage of life may also impact decisions: for one participant who was an accredited supervisor and currently providing co-supervision the “time pressures over the year with a growing family” meant that the participant would not commit to be a main supervisor role at this point in time.
GP supervisors were also cognisant that tensions could also arise when a mismatch emerged between the wages paid to registrars and the income they generated through fee-for service consultations: “They [the registrar] just turned out to be really average and a lot of hard work, and could never get past about two patients an hour” (#11, <5 FTE, outer regional area).
Visiting medical officer services provided to the local hospital needed to be considered within the overall financial models: “If we could convince the hospital of the value of having registrars and find some sort of pay structure that would help” (#15, <5 FTE, outer regional). Another participant thought that the financial models for registrar supervision should be changed in other ways: “The way practices are remunerated, and the way registrars are paid is something that… needs looking at, because initially they are seeing few patients and are not charging enough, so practices lose money (#2, >5 FTE, outer regional).
Some rural GPs wanted to supervise but found they were not able to access a registrar. Participants indicated they wanted a fairer process for registrar allocation, such as “some sort of process that equitably distributes registrars between city and regional centres” (#1, >5 FTE, inner regional area) or “I reckon they should just bloody force them out (#11, <5 FTE, outer regional area).
The uncertainty involved in 6–12 monthly rotational allocations negatively affected business planning, particularly if practices were only sometimes receiving registrars. As noted earlier when a registrar leaves it creates problems as the practice can then have more patients than they can effectively service, with the responsibility for the care of these additional patients falling to the remaining doctors. For rural GPs “continuity would really help. If we knew we were going to get a registrar year in year out, even if they were different levels [of experience], that would help” (#15, <5 FTE, outer regional).
Having the physical space to take on a registrar can also impact the decision to take on a registrar and a registrar’s experiences: “we, at times, have problems with rooms, and I think if you’re going to be a registrar you shouldn’t be shunted from room to room, you need a dedicated room” (#11,<5 FTE, outer regional area).