Five focus group discussions (mean duration 43 minutes, range 35-57) were held in November 2017 with a total of 16 trainees (median group size 3, range 2-5) in Brisbane, Australia. See Table 2 for participant demographic information and Table 3 for focus group membership information.
Table 2: Focus group participant demographic information
All participants
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Age
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mean 32.7, range 26 - 47 years
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Gender
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male 8, female 7
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Country of medical qualification
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Australia 15, UK 1
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Number of years working as a medical practitioner
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mean 5.1, range 3 - 20 years
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General practice training term
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Term 1 1
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Term 2 10
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Term 3 3
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Term 4 1
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Rural or regional general practice experience
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Yes 6, No 10
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Full-time general practice
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Yes (≥8 sessions per week) 9
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No (<8 sessions per week) 7
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Table 3: Focus group information: gender, age, training term, years of medical experience*
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Focus group 1 (N=3)
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Focus group 2 (N=2)
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Focus group 3 (N=5)
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Focus group 4 (N=4)
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Focus group 5 (N=2)
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Participant 1
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M,35,T4,5
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M,31,T2,7
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M,33,T2,3
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M,48,T2,3
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28,M,T1, 3
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Participant 2
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F,26,T3,3
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M,36,T2,6
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F, 30,T2,4
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M,31,T2,3
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47, F,T2, 20
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Participant 3
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F,30,T3,5
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F, 32,T2,3
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F,27,T2,4
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Participant 4
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F,28,T2,4
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NR,NR,T3,4
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Participant 5
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M,29,T2,4
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* Gender (M/F), Age (years), GP training term (T1-T4), Medical experience (years worked as doctor)
Not reported (NR)
Findings are discussed below under the three primary aspects of help-seeking which the study aimed to explore: trainee objectives; trainee activities; and trainee perceptions of the outcomes of seeking help. See Table 4 for themes and sub-themes, and Table 5 for illustrative quotations. Trainees’ own words are used at times (indicated by italics between quotation marks) to retain the participant voice in the paper (30) and to draw attention to trainee choice of language in constructing their accounts.
Table 4 Trainee help-seeking: themes and sub-themes
Trainee objectives
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Trainee activities
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Outcomes of help-seeking
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Managing workflow
The transition
Keeping to time
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Deferring assistance
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Scaffolding trainee skills
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Patient safety
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Constructing help
Selecting help provider
Presenting the case
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Managing uncertainty
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Managing relationships
Patient relationships
Supervisor relationships
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Managing response
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Feedback on help-seeking
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Table 5 Trainee help-seeking: Illustrative quotations
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Trainee objectives
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Managing workflow The transition
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P1: Getting to know the ropes of the referral processes and pathology and the computer
system as well . . .
P2: And just that whole world of community-based services was a bit overwhelming at first
. . . where can I get almost like the best deal for patients . . . A lot of it is by word of mouth
so talking to the supervisors and seeing what other patients have used. FG2
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Managing workflow Keeping to time
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P2: But, yeah, sometimes (waiting for the supervisor) can blow my consult out completely.
P1: Yeah. And then you’ve got issues around the patient waiting . . .
P2: In an ideal world if my supervisor was sitting doing nothing, then I would always get
them in to look at the patient, yeah. FG4
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Patient safety
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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
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Managing relationships with patients
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P2: I’ll say, ‘I don’t know, exactly, what’s going on here, but I think we could do this and I
can talk to somebody more experienced‑ ‑ ‑ I’ll get you back and we’ll talk about it more’.
P1: Yeah, I found a similar thing. 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. FG5
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Managing relationships with supervisors
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My situation’s very different this year and I don’t call for help much at all, and there’s lots of reasons for that. One of them is that I don’t have much of a relationship at all with my supervisor this year . . . they’re not the kind of person that really has much interest in teaching. FG1 P2
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Professional development
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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
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Trainee activities
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Deferring assistance
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P2: At first, I would want help here and now all the time . . . so that was
(Term 1), I’m now coming to the end of (Term 2) . . . I’ll go, ‘Okay. Well, I’m not exactly
sure what’s going on but I know it’s not urgent, I’ve ruled out everything serious’. So, I’m
going to go away, do a bit of a reading or I’m going to take this case at lunch time and
discuss it. So that pattern’s changed. I mean I still ring them here and now, can you come
and look at this, but not all the time. I’m confident. And again, I think it’s a confidence
thing to say, well, I know this can definitely wait.
P1: Yeah, I find a very similar thing.
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Constructing help Selecting a help-provider
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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.
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Constructing help Presenting the case
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It depends on, on the person I am speaking to um, as to what their style is, how they like
the registrar interaction to go and you get a feel for that as you work in the practice for
longer. Um, but yeah usually everyone appreciates you being direct upfront about what
you need. And then showing that you have given some thought to it beforehand P1FG2
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Managing response
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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
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Outcomes of trainee help-seeking
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Scaffolding trainee clinical skills
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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
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Managing uncertainty
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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
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Feedback on trainee help-seeking
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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
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Trainee objectives
Managing workflow Managing the transition to general practice
Participants consistently reported having sought help frequently during their initial transition from hospital practice into “the wild safari” of general practice. Trainees described themselves as “coming across as really needy”, “having no idea” and being “overwhelm(ed)” (see Table 5), indicating their discomfort and uncertainty at this time. Initially trainees needed assistance to obtain information about practice software and other facilities, and the “complex maze” of local patient resources and referral preferences. Supervisors, practice staff and patients themselves all contributed to building up this trainee “database”. For many trainees, responsibility for patient management decisions, the general practice setting, and some clinical presentations were unfamiliar. Trainees also 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.
Managing workflow Keeping to time
It was common for trainees to contrast this initial stage with being able to considerably reduce their in-consultation help-seeking by the second month of the first term. Trainees still sought in-consultation assistance when they were “stuck” in a consultation, but it was clear that time constraints had a major impact on help-seeking decisions, because trainees needed to keep up with patient appointment schedules. Trainees described deferring discussion about patients when either they or their supervisors were busy. When they did seek in-consultation help, they avoided asking supervisors who might unduly delay the trainees’ consultations, and sometimes sought brief advice over the phone (unless sighting the patient was necessary to establish a diagnosis) when they would have preferred a longer face-to-face interaction with the supervisor in the room with the patient, in an “ideal world” (see Table 5). Waits of up to 20 minutes were reported when supervisors completed their own consultation before providing help. Several stories were told of the trainee moving forward with patient management while waiting for the supervisor, risking the embarrassment of having to “wind back” plans and “backpedal” if the supervisor subsequently changed these.
Patient safety
Trainees commonly spoke about their help-seeking after the initial transition as “getting a second opinion”, “double checking” when they were “not 100% sure”, and “making sure” that they were “not missing anything”. They emphasised the importance of being (and demonstrating that they had been) safe, and frequently talked in terms of being able to “sleep at night” only if they were confident that their management was safe.
The clinical contexts of trainee accounts of help-seeking often highlighted concerns about patient safety, including several scenarios in which decisions had to be made about whether to admit a patient to hospital, or rely on patients and their families to monitor for any clinical deterioration. These clinical contexts included febrile children, adults with chest pain and patients with suicidal ideation. Several trainees emphasised that patient safety was always their highest priority (see Table 5).
Managing relationships with patients
Other scenarios for help-seeking which were each mentioned by several trainees included patient requests for drugs of dependence or another clinical opinion, and regular patients of another general practitioner in the practice with ongoing problems. In these scenarios trainee decisions may be particularly subject to criticism by patients and/or colleagues, and help-seeking appeared to be a pre-emptive move to ensure trainee psychological safety.
Many trainees portrayed themselves as having become comfortable managing patient relationships while seeking help. Several reported that although they had been anxious about patient impressions of their competence earlier in their training when admitting gaps in their knowledge, they no longer had these concerns when framing help-seeking as getting a second opinion (see Table 5).
However a few trainees reported losing ‘face’ in front of patients due to supervisor breaches of the etiquette of help provision, a key aspect of which is 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” with the patient or exploring trainee concerns. Another participant reported that his ego was “shredded” whenever his supervisor provided help, due to what the trainee perceived to be an excessive “show” of supervisor expertise to the patient which belittled the trainee’s own competence.
Managing relationships with supervisors
Trainees typically used informal and non-hierarchical language to describe their help-seeking interactions, (“just having a chat”, and even “helping each other work out a plan”), and their requests of supervisors (“having a quick look” at the patient, and “having a feel of her tummy”, in contrast to formal medical language (“examining the patient” and “palpating the abdomen”). Their use of this almost off-hand language may have been intended to convey impressions of trainee confidence and status, and to re-frame their help-seeking from a need for assistance from a superior to a casual collegial interaction. Several trainees admitted, however, to being anxious that too much help-seeking would unduly burden supervisors, or give the impression that they “knew nothing”. Discussions about getting “back-up” from “the boss”, and comments that supervisors had a role in assessing, and often employing, trainees, also suggested that trainees remained aware of a power differential in the supervisor-trainee relationship.
Trainees described seeking help more frequently when they had a close relationship with their supervisor (see Table 5), irrespective of their stage of training. Trainees in one group reported that other trainees in less accommodating practices than their own avoided asking questions and “cut corners” to manage 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“. These comments suggested that trainees with weaker trainee-supervisor relationships were uncomfortable seeking assistance or initiating these conversations. Several trainees were also reluctant to “burden” other general practitioners in their training practices who were not supervisors, with one trainee explaining that they would be helping “out of the kindness of their heart”.
Professional development
Trainees talked about being “here to learn” and their wish to “soak in” as much knowledge as they could, while they were trainees, particularly from supervisors who they perceived to be particularly clinically astute. Several trainees had intentionally selected their training practices because of the good reputation of these supervisors among hospital clinicians, and others also valued opportunities to observe expert clinical practice:
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
Trainees described wanting to take opportunities during training to find out more about other doctors’ approaches, what they were “doing in their rooms” and how their own practice measured up. These discussions conveyed a sense of trainee isolation and vulnerability, their awareness that their own practice might be exposed to criticism, and a somewhat precarious sense of the “right thing to do” (see Table 5). This contrasted with the more confident, casual approach to seeking help which was portrayed elsewhere in the discussions, and positioned the trainees as having legitimate claims on supervisors for assistance.
Help-seeking activities
Deferring in-consultation assistance
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. Trainees reported becoming confident deferring assistance by using temporising strategies and scheduling patient reviews or contacting patients outside theconsultations if management changes were suggested at the deferred discussions (see Table 5).
Secure a help-provider
Trainees preferred to seek help from trusted supervisors who were readily accessible (see Table 5). The trainee preference for not interrupting supervisors sometimes led them to wait in corridors and outside consulting or treatment room doors to catch a supervisor in between consultations. Trainees described this activity as “hovering” and “loitering”, using irony to draw attention to the awkwardness and inefficiency involved. If trainees elected to interrupt a supervisor, they typically phoned the supervisor from their consulting rooms.
Several trainees reported that they preferred to distribute 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, where more than one supervisor was available.
Case presentation
Trainees commonly presented their request for assistance over the phone within the patient’s hearing. However they also reported reasons for preferring to seek help outside the patient’s hearing, including: not wanting information in the case presentation to upset, worry or offend the patient; to conceal the extent of the trainee’s uncertainty from the patient; and to avoid 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 reported that the activity of presenting to their supervisor often clarified their thinking, and even just stepping away from the patient allowed trainees to collect their thoughts:
Sometimes if my head is bursting I will go out, on the pretence of trying to find my
supervisor [laughs] . . . get my head together FG4P2
Trainees described supervisors wanting concise and “direct upfront” problem presentations (see Table 5) which included a management plan if possible. Most trainees appeared to use medical terminology for these case presentations, although one participant reported using lay terms when the patient was present.
Managing responses
Trainees reported avoiding further in-consultation assistance from supervisors who had breached etiquette or provided poor advice. 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 other 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 this advice despite misgivings, culminating in the trainee ‘chasing up’ patients after hours with abnormal investigation results requiring urgent admission (described by one trainee as “a big fiasco”). However other trainees reported witnessing good outcomes from following 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
A number of stories were also told of unsatisfying advice which 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 the wider issue of financial abuse by an elderly patient’s relative.
Several trainees reported always following their supervisor’s advice, although several others reported having disregarded this on occasions, sometimes after seeking another opinion. One trainee reported that “what this taught me is that it’s ok to do it differently. That there isn’t always one right answer”. Disregarding advice was also justified in terms of the trainee having “to sleep at night”, and the uneven nature of supervisor expertise, so that some advice should be taken “with a grain of salt” (see Table 5). Most trainees who reported having disregarded their supervisor’s advice did appear to find this situation awkward and several reported concealing this from their supervisor.
Help-seeking outcomes
Scaffolding trainee clinical skills
Although there was a consensus that there was rarely time to teach during in-consultation help-seeking interactions, several trainees reported picking up “learning points”. Trainees appeared to appreciate supervisors who talked through their thinking for the trainee’s benefit, and supervisors who used probing questions to scaffold their clinical problem-solving (see Table 5). A “good teacher” 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
Managing uncertainty
Many trainees reported coming to accept clinical uncertainty, as something that they had to “learn to live with” as general practitioners. Several trainees reported being reassured and impressed when they witnessed their supervisor admitting and managing his or her own uncertainty in front of their patient. They also commented appreciatively on senior general practitioner colleagues who discussed their own cases, with “no-one’s thinking they know it all”. Participants reported becoming “comfortable with uncertainty”, provided that they knew “the process” or “the steps” for managing consultations, and “readjusting (their) perspective” to solving problems in general practice over a number of consultations (see Table 5). However, several trainees also mentioned seeking help from general practitioners or senior trainees who were “always bloody right” or “very, ridiculously smart”, suggesting an ongoing belief that it might often be possible to know the ‘answers’.
Feedback on trainee help-seeking
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).
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” clinical decisions themselves, in several cases framing this response as “pushback” (see Table 5). 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 appropriate for the trainee to make the management decisions:
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 . . . seeing them, like every week or so, we’ve had that rapport, we know more of the history, and the short… sentence, we provide the supervisor with is not necessarily all the stuff that we’ve gained from the patients ... So, I think it’s more that they want us to be confident with our capabilities… rather than ‘push back’. FG3P1