Findings are discussed below under three major categories: help-seeking objectives; help-seeking activities; and help-seeking outcomes.
Participants consistently reported having sought help frequently during their initial transition from hospital practice into "the wild safari” of general practice, and this was contrasted with reduced help-seeking after the first "two to eight weeks”.. Initially trainees needed assistance to obtain information about practice software and other facilities, and the "complex maze” of local patient resources and referral preferences. For many trainees, general practice was clinically unfamiliar, as was their responsibility for patient management decisions. Trainees reported that it was “comforting” to have confirmation of their plans in situations which they were encountering for the first time, such as calling an ambulance to transfer a patient to hospital, instead of "second guessing” themselves.
It was common to contrast this initial stage with subsequent help-seeking. Instead of "coming across as really needy” and "having no idea”,, trainees described their later help-seeking as "getting a second opinion” and "double checking” when they were "not 100% sure”.. In general, participants described their help-seeking in informal, non-hierarchical, lay language, using terms like “just having a chat”, “having a quick look”, “having a feel of her tummy” and “helping each other work out a plan”.
Trainees also often described their help-seeking as "making sure” that they were "not missing anything”.. They talked about the importance of being (and demonstrating that they had been) safe:
P2: And you want to make sure that you are safe. And that you have shown that you have
been safe by discussing with your supervisor about something that you—you are unsure about.
Q: Showing to the patient or to the supervisor or?
P2: I think to yourself. To the medical legal systems, to the patient and to your supervisor.
What everyone wants to know is that you are safe in your practice as a registrar and that, if
you are unsure, then you will talk to someone FG3 (Focus group 3)
Help-seeking stories included several scenarios in which decisions had to be made about whether or not to admit a patient to hospital. These clinical contexts included febrile children, adults with chest pain and patients with suicidal ideation. Participants often talked about having to "sleep at night” to convey their sense of the risk of managing these patients at home, relying only on patients and their families for monitoring. Other scenarios for help-seeking which were mentioned by several trainees included skin conditions, 'drug-seeking’ patients, requests from patients for another opinion, and regular patients of another general practitioner in the practice with ongoing problems. Trainees also reported that it was sometimes valuable to take "time out” away from patients to collect their thoughts:
Sometimes if my head is bursting I will go out, on the pretence of trying to find my
supervisor [laughs]... So, if my head’s bursting and I don’t know what’s going on and I’m
not confident in giving a history over the phone with the patient listening, then I will go out,
get my head together FG4P2 (Focus group 4, participant 2)
Trainees described wanting to take opportunities during training to find out more about other doctors’ approaches:
You kind of are wondering, “What are all these other GPs doing in their room?” You know what I mean? Is what I am doing the standard? And you can look up guidelines and stuff. But so much of what we do—there’s a lot of grey. And so getting a sense of what is a—you know what is—what are my colleagues doing? What is the expectation—both from a legal perspective but also just from a practical, what is the right thing to do, perspective. Um, and I think that is what we need to get a good sense of, in these two years that we do have supervisors available FG2P3
Participants talked about being "here to learn” and "soak in” as much knowledge as they could from supervisors who they perceived to be particularly clinically astute. They also commented appreciatively on senior general practitioner colleagues who discussed their own cases, with "no-one’s thinking they know it all”. However there was some ambivalence about it being "OK that you don’t know the answer” and several trainees mentioned particular general practitioners or "very, very smart” senior general practice trainees who might in fact know all the answers:
You ask the person who you really trust who’s just going to give you a quick opinion and who’s always bloody right! FG5P4.
Help-seeking typically involved an initial attempt to solve the problem independently, for example by reviewing patient records for previous management strategies or searching online. A more accessible source of advice than the supervisor, such as a practice nurse, was sometimes contacted. If these steps were unsuccessful, a decision was then made about whether help-seeking could be postponed to a more convenient time, in order to reduce the disruption to their own and their supervisors’ consultations and enable more relaxed discussions. If "the answer” was required during the consultation, trainees attempted to locate a supervisor who did not need to be interrupted with their own patient, and who was likely to provide a timely response. This activity included studying the appointment schedules and patient waiting times of other general practitioners, and "hovering” or "loitering” in corridors and outside consulting room or treatment room doors. Several trainees reported that they distributed their help-seeking to reduce the load on any one general practitioner, and several described "cherry-picking” help providers based on perceived areas of provider expertise and their approach to managing risk, although a few participants reported having only one supervisor. Some trainees also reported seeking further advice from other sources if they were uncomfortable with, or dubious about, the advice received. Participants seemed somewhat ambivalent about whether this was disrespectful or justified:
I do have the opportunity to ask - canvas different opinions. And um, I, kind of, made the decision that I wasn’t going to do that. I didn’t think that was very, um, ethical, in terms of asking somebody and then going and asking somebody else. I kind of - perhaps disrespectful. Perhaps disrespectful is a better word. Having said that I did do it once. FG4P2.
Trainees typically phoned their supervisor from their consulting rooms, presenting their request over the phone within the patient’s hearing. However they also reported a number of reasons for preferring to seek help outside the patient’s hearing, including the following: not wanting information in the case presentation to upset, worry or offend the patient; concealing the extent of the trainee’s uncertainty from the patient; and avoiding the patient overhearing supervisor advice which the trainee might choose not to follow. One participant described "jumping up” to leave the consulting room as she noticed the supervisor approaching, in order to speak to the supervisor before he came in. Trainees described supervisors wanting them to be concise and "direct upfront” when presenting patients, "showing that they had given it some thought”,, and to propose a management plan if possible. Several reported using medical terminology in these presentations, although one participant reported using lay terms within patients’ hearing.
While much in-consultation advice was sought via brief phone conversations, trainees also reported that it was often useful to witness the supervisor interacting with their patient:
You know, so he could, you know, look at his patient and sum the whole patient up and work
that out, just with that clinical experience. You know, that was right and that was a really
useful experience, to actually see that interaction FG4P2
One trainee even commented that “in an ideal world” they would always prefer the supervisor to come into their consultation to provide help. However, trainees were anxious about delaying their own consultations by waiting for the supervisor to come in, and mindful of time constraints and other pressures on the supervisors themselves:
P1: From my perspective I don’t ask the people who are really behind
P2: Yeah, no.
P4: Yes, yes.... It’s just up to us to use the best—draw the best potential out of the supervisor FD5.
Many trainees reported positive outcomes from help-seeking, including picking up 'learning points’ and coming to terms with ongoing clinical uncertainty, as something that they had to "learn to live with” as general practitioners. Several trainees reported being particularly reassured and impressed when they witnessed their supervisor admitting and managing his or her own uncertainty in front of their patient. Managing trainee uncertainty was also assisted by "readjusting their perspective” to the general practice setting, and staging management over several consultations rather than trying to definitively solve "all a patient’s problems at one sitting”:
The thing that one of my supervisors said to me one day when I was asking her about someone... she was, like, ‘Well, is she going to die today?’ like, quite blunt and I was, like, ‘No, actually’... I could say to this woman, ‘Let’s give this a try and I’ll see you in a week to two weeks and we’ll follow it up’... coming to grips with that change in general practice which is that it is a lower acuity, stuff that you do over a longer period of time FG5P1
Participants reported becoming comfortable not knowing "the answer”,, provided that they knew "the process” for managing consultations:
P1: Learning to become, like, comfortable with uncertainty
P4: Yeah, yeah, yeah.
P1: And that, yeah, it’s okay that you don’t know the answer but
P4: You know the process, yeah
P1: Yeah, you know the steps. FG4
Several trainees expressed great respect for their supervisors’ clinical judgement, including trainees who had intentionally selected their training practices because of the good reputation of these supervisors among hospital clinicians. Supervisors who talked through their thinking for the trainee’s benefit, and supervisors who "flesh it out of us” or scaffolded their problem-solving appeared to be particularly appreciated:
P3: Yes, you’ve asked for their opinion but they’re just fleshing it out of you...
P1: And she’s, like, ‘And what else could it be?’... And then you, kind of, have had that chance
to synthesise your thoughts and in—with basically, like, having a person in your brain going
‘yeah, yeah, you’re doing good, you’re doing good, you’re doing good, yeah, you got it’ FG4
Trainees also discussed a number of adverse or mixed outcomes from help-seeking during consultations, and several reported avoiding in-consultation assistance from supervisors with whom they had had a negative experience. Adverse outcomes from help-seeking included delay and disruption to trainee workflow, pushback from supervisors, etiquette breaches by supervisors, and uncomfortable advice. These outcomes are expanded upon below.
Delay and disruption to workflow
Waits of up to 20 minutes were reported while supervisors completed their own consultation before providing help. Several stories were told of the trainee moving forward with patient management decisions while waiting for the supervisor, risking the embarrassment of having to "wind back” plans and "backpedal” once the supervisor arrived. A "good teacher”,, on the other hand, could provide help efficiently:
He’s in and out in three minutes but it’s quality, not wanting the whole consult re-done but giving the impression of being unhurried and thoughtful, and he interacts with the patient and reveals his thinking. FG4P4
Trainees did not report any explicit discouragement from their supervisors to seek help, except for a single mention of audible supervisor sighs on the phone (which seemed to surprise the other trainees). However participants in one group reported knowing other trainees in less accommodating practices who avoided asking questions and "cut corners” because of workflow pressures. Another trainee commented that he would have liked his supervisor to "regularly check in... to kind of say ‘Is this working for you?’” rather than "assuming everything is all right“..
Some ambivalence was expressed in a number of discussions about supervisors asking trainees to propose a plan and “trust your judgement”.. On the one hand, trainees were sometimes dissatisfied with "just hav(ing) to call it”,, in a few cases framing this response as "pushback”::
So I called up my boss and I said like, ‘Would you mind having a feel of her tummy and seeing what you think?’... (The supervisor) is like, ‘Well what—what do you think should happen?’ I’m like, ‘I think she should go to hospital.’ He said, ‘Well, that is what should happen I guess.’ In a way kind of saying, “Well, do I really need to see her?”... Like I realise that I should be trusting my instincts but in these two years I am here to learn and I am here to get a second opinion about things... from a community setting, I think it’s useful. And there was maybe just a little bit of pushback there about something that they felt was an obvious answer FG2P2
On the other hand, trainees also reported that the encouragement to formulate their own management plans had built up their confidence and that it was probably more appropriate in many cases for the trainee to make the clinical calls:
And then, like, at the end of the day we are their treating practitioner and we still have our supervisor for back up if we need it, but we have been managing this patient, like, if we’ve been seeing them, like every week or so, like, we’ve had that rapport, we know more of the history, and the short, I guess, sentence, we provide the supervisor with is not necessarily all the stuff that we’ve gained from the patients as well. So, I think it’s more that they want us to be confident with our, like, capabilities, as well, more so rather than push back. FG3P1
Trainees reported some supervisor breaches of the etiquette of help provision, resulting in trainee loss of face. A key aspect of this etiquette was not undermining patient impressions of the trainee’s expertise. One participant described being "burned’ by an abrupt, "old school” supervisor who gave simple, direct advice without engaging in any "chit-chat” to the patient or addressing the trainee’s underlying questions. Another participant reported that his ego was "shredded” whenever his supervisor provided help, due to what the trainee perceived to be an overly-reassuring "show” to the patient which belittled the trainee’s own expertise. However several other traineesreported that they had been more anxious about patient impressions of their competence earlier in their training, and no longer had these concerns:
Just being able to just say straight up to patients ‘I’m not sure what’s happening, I’m not
entirely sure what’s going on’. A lot of the time they actually seem oddly reassured by that
[laughs]... and they seem to think, ‘oh, I’m getting a second consult’, um, you know, ‘I’m
getting a lot of attention’, that’s why I find patients generally like it. FG5P1
Several trainees reported being surprised by supervisor advice to manage patients at home, instead of admitting them to hospital. A few trainees told ‘cautionary tales’ of accepting the supervisor’s advice, culminating in the trainee 'chasing up’ patients after hours with abnormal investigation results requiring urgent admission (described by one trainee as "a big fiasco”),), and deciding not to seek supervisor advice again if they were clear in the future that hospitalisation was indicated. However other trainees reported witnessing good outcomes from advice to manage patients at home, and that this had changed their future practice. Several participants referred to the diversity in general practitioner approaches to managing risk and referrals. Supervisors who appeared too ready to refer patients were discussed as well as others who appeared too reluctant:
My GP... it’s ideology, or whatever it is, sort of has this view of sending patients to hospital is a failure, when he—he thinks he can easily be able to solve everything FG1P1
Several trainees reported advice to prescribe antibiotics which conflicted with their understandings of antibiotic stewardship (although one trainee reported accepting advice to prescribe antibiotics for a patient he had intended to manage conservatively 'because it wasn’t such a bad argument actually’).). Several trainees reported always following their supervisor’s advice, although several others reported having disregarded this on occasions, sometimes after seeking another opinion. This was justified in terms of the trainee having "to sleep at night”,, and in terms of the uneven nature of supervisor expertise so that in some areas it could be taken "with a grain of salt”::
I think it’s probably the GPs that have been GPs for many, many years, with patients that expect certain things, it’s hard for them to perhaps start to change their practice in a way that’s more in line with antibiotics stewardship... the necessity for antibiotics sometimes, you’ll take that really with a grain of salt, and see whether you’re reasonable in not prescribing and having a good return plan FG3P2
Most trainees who reported having disregarded their supervisor’s advice did appear to find this situation awkward, however, and several reported concealing this from their supervisor. One trainee described feeling obliged to follow a supervisor’s practice, and to "be a certain type of GP” at that training practice, due to the supervisor’s position as his employer and assessor.
A number of stories were also told of advice which was less than fully satisfying, where it seemed to address only one aspect of a more complex problem. Contexts included restricting the prescription of opiate analgesia to an opiate dependent patient, and referring a patient for assessment of their cognitive competence in a situation which appeared to involve financial abuse by a relative of an elderly patient.