Reflections
Volume 198 - Issue 11

Remote supervision in postgraduate training: a personal view

Author:  Susan M Wearne

Med J Aust 2013; 198 (11): 633-634. || doi: 10.5694/mja13.10296
Published online: 17 June 2013
Telehealth could enable real-time interactions between registrars, patients and remote supervisors, and create medical training places in outback Australia
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Using telehealth infrastructure for remote supervision could create medical training places where they are needed

Remote supervision is used increasingly in postgraduate general practice training in outback Australia and northern Canada.1,2 In this model, general practice supervisors and registrars working in different locations communicate via information and communication technology. However, the concept of remote supervision compared with the traditional apprenticeship of general practice training raises questions about how registrars can learn without observing their general practice supervisors at work. And how do general practitioners supervise registrars without overseeing them?

Remote supervision began as a trial to give registrars experience of solo general practice during training. General practice supervisors supplemented phone communication with onsite teaching visits.3 This pilot project met the training standards without any reports of adverse patient outcomes.3 It led to the formation of the Pilot Remote Vocational Training Stream and then the Remote Vocational Training Scheme (RVTS).1

After relocating to Central Australia, I became a remote supervisor and then medical educator with the RVTS. Many registrars thrived and developed in ways that challenged my traditional definitions of quality clinical education. In 2007, 21 doctors out of 24 had completed training; 17 of these registrars did all their general practice training in very remote locations. Most still worked in rural areas and 20 had College Fellowships.4 By 2012, 70 general practice registrars were training via remote supervision with RVTS,5 as were a small number of doctors in the Australian College of Rural and Remote Medicine Independent Pathway. Real-time interactions between registrars, their patients and remote supervisors are now possible; in Canada, supervisors manage emergencies via videoconference6 and can remotely control a robot to read registrars’ notes and assess patients by remote ultrasound scan.

Despite the expected difficulties of identifying registrars’ blind spots at a distance, remote supervisors were also enthusiastic about this model of training. They felt liberated from the managerial and assessment roles of onsite supervisors and could support registrars in tailored educational relationships.7

The expansion in the number of medical graduates, from 1915 in 2009 to 3254 in 2016,8 is increasing demands on training positions and the clinicians who oversee supervision and training.9 More generalists are required, as is training in regional, rural and remote locations,10 which should equip and encourage doctors to practise there once qualified.11 Different models of clinical teaching that can deliver extra training capacity without diluting quality are needed.12

The federal government is funding telehealth to improve access to medical services for Australians who cannot get to a specialist, or who live in rural and remote areas.13 This has resulted in investment in information and communication technology infrastructure and familiarity in using it for meaningful and important interactions. This shift in clinical practice creates opportunities for a parallel educational shift to provide extra training posts by extending remote supervision. Indeed, the Royal Australian College of General Practitioners standards scheduled for introduction in 2014 allow remote supervision,14 so this training model could be introduced in other rural locations15 or underserved areas of primary care such as clinics for refugees. To make this happen, reliable and fast internet access is needed nationwide, with 24-hour access to equipment and technical support.

Accredited training places for specialties other than general practice could also be provided at remotely supervised training posts. Registrars who have almost completed training could undertake regional, rural or remote fellowships. Gaps in the ability of local staff to provide clinical supervision would be supplemented by supervision from tertiary centres, using the facilities now in place for telehealth, to create a supervision team with local contextual and subspecialty expertise.

Remote supervision poses broader structural challenges. There are inevitable tensions for registrars in work-based learning — from feeling used and exploited by too many clinical demands to having limited access to clinical experiences and authentic learning opportunities. Getting an optimal balance is harder to achieve remotely. Also, supervisors usually provide dedicated teaching time and review patients in response to registrars’ questions. In contrast, safe remote supervision requires changes to supervisors’ workflow, to allow significant time and commitment to proactively contact registrars and monitor their work. It should not be an untimetabled or unbudgeted extra. Registrars, their families and supervisors should be carefully selected, supported and their wellbeing monitored by educational organisations.16

The assumption that quality medical training only occurs in major centres risks perpetuating Australia’s maldistribution of medical workforce and health care expenditure by location rather than clinical need. Remote supervision — within a package of educational and family support, and changes to supervising specialists’ funding and routines — is one option to redress the balance.

Author

  • Susan M Wearne MMedSc, FRACGP, FACRRM1
  • 1. General Practice Education and Training, Canberra, ACT.

Correspondence: susan.wearne@gpet.com.au

Competing interests

No relevant disclosures.

Acknowledgements

I thank Flinders University, Adelaide, for library access, and my employer, General Practice Education and Training, for support; however, the views expressed are my own and not necessarily those of General Practice Education and Training.

References

Provenance: Commissioned; externally peer reviewed.

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