Teaching in practice

Annabel McGilvray
Med J Aust
Published online: 7 October 2013

Australia’s medical apprenticeship system is undergoing dramatic growing pains and more is being demanded from our clinical teachers, trainers and supervisors than ever before.

The medical apprenticeship has a history stretching back at least as far as the Hippocratic Oath. It’s an integral part of all medical careers and for many doctors is part of their entire working life — first as student, then intern, junior doctor and registrar, and later as teacher, trainer or supervisor.

But the recent dramatic growth in the numbers of those on the learning side of the relationship — the students, interns, junior doctors and registrars — without any corresponding increase in numbers on the teaching side — the teachers, trainers and supervisors — means it is a model under pressure.

Alongside increasing student numbers, the accreditation and training requirements for providing clinical education have increased dramatically within the past decade, putting greater strain on the hospitals and practices seeking to provide on-the-job experience and guidance for the next generation of doctors.

Anecdotally, clinical teachers in all sectors of the profession are working at close to maximum capacity. Some general practices are beginning to feel more like education campuses and teaching hospitals talk about not having sufficient patients to service the students rotating through — sometimes as many as six to a ward.

Chair of General Practice Supervisors Australia (GPSA), Trish Baker, says these pressures have made it increasingly difficult to recruit and maintain the pool of supervisors in general practice. “But most people who do it, do it because they love it”, says Dr Baker. “It’s very sustaining for them professionally and most of us would say we learn as much from our registrars as they learn from us. There’s renewal. It revitalises the practice. It’s good for everybody.

“We certainly don’t do it for the money.”

In a small step towards addressing the problems, on the eve of the election the Coalition pledged $119 million towards doubling the practice incentive payment (PIP) for general practices that host medical students, from $200 per student per day to $400 per student per day.

It also promised $46 million for grants to improve general practice teaching and supervision infrastructure (see box).

What difference is this new money likely to make for those doctors already teaching and training? How are our clinical teachers bearing up under the new pressures? And what is it that makes a good clinical educator?

Teaching on the run

Dr Fiona Lake is a respiratory physician who often has a slew of students and trainees with her when she does her ward rounds. Those learning at her side at Fremantle Hospital on any one round may include a fourth-year student, a sixth-year student and a registrar.

Dr Lake is one of the developers of Teaching on the Run, one of Australia’s few non-degree courses designed to help clinical educators teach more effectively. Since its establishment in 2001, more than 1000 clinical teachers have completed the workshops and online modules.

Some of the key points from the course, which is taught at up to 70 workshops around the country each month, include:

  • providing effective feedback — understanding how, when and why;
  • identifying teaching moments — structuring rounds or consultations to allow time for teaching; and
  • teaching skills — basing teaching around Rodney Peyton’s four-step approach: demonstration, deconstruction, comprehension and performance.

Dr Lake bases her own teaching on the idea that if something can be learnt from a textbook, it is of no help for her to teach it as well. “It’s a complete waste of time for me to teach it!

“The way to use clinicians is to fill in all of that other stuff, to give people experience, giving feedback about what they’ve done. Getting them to understand processes like clinical reasoning and how you apply it to patients.”

Teaching on the Run is offered to all registrars training at the Royal Prince Alfred Hospital (RPA) in Sydney, one of New South Wales’s leading tertiary teaching hospitals. Director of Physician Training at RPA, Dr Ted Wu, says it is part of providing trainees with a more rounded education, looking beyond examinations and assessments.

The endocrinologist says there is great enthusiasm from younger doctors to be involved in teaching, partly as it has become a necessity in order for applicants to distinguish themselves when applying for future roles.

Dr Wu has been helping to manage the hospital’s training programs for nearly 10 years and says they try to encourage greater recognition of the importance of the role.

“The role of clinicians as teachers I think is sometimes under-recognised.”

To address this and reward outstanding teaching skills, the RPA gives end-of-year prizes for the best consultant and the best advanced trainee, chosen by popular vote.

Ultimately, Dr Wu says the best teachers are those who recognise the importance of teaching and have an enthusiasm for it. “People think you need to have a great knowledge or great skills. No, the vast majority of doctors are smart people. They know their stuff already. People think they need to have some superhuman knowledge to become a good teacher but that’s not true.

“An enthusiasm and an appreciation of teaching is an important thing both for the future generation and for themselves. Teaching is often one of the best ways to learn.

“It keeps me on my feet.”

Regardless of enthusiasm or ability, like Dr Lake in Western Australia and specialists teaching in hospitals around the country, Dr Wu is concerned about the combined pressures on clinical education of increasing student numbers, a shrinking proportion of patients suitable for teaching and no apparent increase in resources.

At RPA the number of vocational trainees accepted in the past 6 years has increased by more than half, without any corresponding increase in those providing the teaching or administration support. And for the 30 positions available, there were more than 400 applications.

“If hospitals can’t fund any more clinician places, then there are no more senior clinicians to supervise or train these people”, Dr Wu says. “And there is now a tiny proportion of patients who are appropriate for teaching purposes because they’re not too sick but have some visible or usable pathology. That small group of patients are overwhelmed by requests from either students, interns, residents or registrars. There’s a certain level of fatigue, I think, among the patients.”

Looking ahead, with student numbers set to continue increasing in the near future, the pressures facing Australian medicine’s currently shaky apprenticeship system are among those put forward for consideration by Health Workforce Australia’s yet-to-be-established National Medical Training Advisory Network.

In the meantime, increased funding such as the new government’s boost to the PIP for teaching in general practice may go some way towards preventing the gap between the number of teachers and learners increasing even further in at least one sector of the profession.


New funding for general practice teaching

The recent promise to boost to the practice incentive payment for teaching has been welcomed as a long overdue recognition of the value of general practice teaching to the development of the profession and the financial impact that it has on private practice income.

When implemented it will mean that practices will no longer lose money when they take on medical students.

For example, teaching a medical student is likely to mean that a general practitioner will see fewer patients over an hour — perhaps three instead of four — in order to properly introduce and brief the student and the patient before each consultation.

This means seven fewer patients in any one session. But the running costs of the practice don’t change during that time, effectively meaning a $350 hit to the practice bottom line.

Under current arrangements, practices receive $200 per day to cover the cost of having medical students, resulting in a loss of $150 per session per student. With the government’s promised doubling of the compensation to $400 per session, GPs may now earn $50 each day for the teaching contribution.

Similarly, the new funding for infrastructure is likely to help general practices to create the extra room required when providing supervision for registrars as they need a consultation room to practice from.

Dr Trish Baker says the big issues for general practice training are capacity and capability issues that have been created by the addition of prevocational training in addition to medical students and registrars.

At the same time she says supervisor recruitment and maintenance has become difficult over the past decade as the accreditation and compliance demands have dramatically increased.

“A lot of practices today are basically working as integrated educational centres. There may be the situation where you have a registrar or two, you’ll have a medical student or two, you may have a nursing student, you may have an allied health student.”

Even with the increased government funding, the business case for training in general practice is still to be made, Dr Baker says.

“If you offer a practice a choice between having a full-fellowship and experienced GP who can operate independently and doesn’t need any supervision and will stay in a practice, or a registrar who will inevitably turn over and need supervision, the business case is a no-brainer: you don’t teach; you don’t supervise.”



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