Skip to main content
SpringerLink
Log in

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning

  • Published:
Advances in Health Sciences Education Aims and scope Submit manuscript

Abstract

Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and ‘patient entrustment’ (patient confidence in the trainee’s clinical management). Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Biondi, E. A., Varade, W. S., Garfunkel, L. C., Lynn, J. F., Craig, M. M., Cellini, M. P., & Baldwin, C. (2015). Discordance between resident and faculty perceptions of resident autonomy: Can self-determination theory help interpret differences and guide strategies for bridging the divide? Academic Medicine, 90(4), 462–471.

    Article  Google Scholar 

  • Bleakley, A., Bligh, J., & Browne, J. (2011). Medical education for the future identity, power and location. Dordrecht: Springer.

    Book  Google Scholar 

  • Brown, J., Nestel, D., Clement, T., & Goldszmidt, M. (2018a). The supervisory encounter and the senior GP trainee: Managing for, through and with. Medical Education, 52(2), 192–205.

    Article  Google Scholar 

  • Brown, J., Wearne, K. C., Snadden, S., & Smith, D. M. (2018b). Review of Australian and international models of GP vocational training and education. Bendigo: MCCC.

    Google Scholar 

  • Byrnes, P. D., Crawford, M., & Wong, B. (2012). Are they safe in there? Patient safety and trainees in the practice. Australian Family Physician, 41(1–2), 26–29.

    Google Scholar 

  • Cianciolo, A. T., & Kegg Jason, A. (2013). Behavioral specification of the entrustment process. Journal of Graduate Medical Education, 5(1), 10–12.

    Article  Google Scholar 

  • Clement, T., Brown, J., Morrison, J., & Nestel, D. (2016). Ad hoc supervision of general practice registrars as a ‘community of practice’: Analysis, interpretation and re-presentation. Advances in Health Sciences Education, 21(2), 415–437.

    Article  Google Scholar 

  • Cupchik, G. (2001). Constructivist realism: An ontology that encompasses positivist and constructivist approaches to the social sciences [33 paragraphs]. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 2(1), 7. http://nbn-resolving.de/urn:nbn:de:0114-fqs010177 .

    Google Scholar 

  • Duijn, C., Welink, C., Bok, M., & Cate, A. (2018). When to trust our learners? Clinical teachers’ perceptions of decision variables in the entrustment process. Perspectives on Medical Education, 7(3), 192–199.

    Article  Google Scholar 

  • Ende, J., Pomerantz, A., & Erickson, F. (1995). Preceptorsʼ strategies for correcting residents in an ambulatory care medicine setting: A qualitative analysis. Academic Medicine, 70(3), 224–229.

    Article  Google Scholar 

  • Eva, K. W., & Regehr, G. (2008). “I’ll never play professional football” and other fallacies of self-assessment. Journal of Continuing Education in the Health Professions, 28(1), 14–19.

    Article  Google Scholar 

  • Flin, R. (2018). A practice-based approach to safety as an emergent competence. In C. Bieder, C. Gilbert, Bt. Journé, & H. Laroche (Eds.), Beyond safety training: Embedding safety in professional skills (pp. 45–58). Cham: Springer Open.

    Chapter  Google Scholar 

  • Frank, A. W. (2013). From sick role to practices of health and illness. Medical Education, 47(1), 18–25. https://doi.org/10.1111/j.1365-2923.2012.04298.x.

    Article  Google Scholar 

  • Franzone, J. M., Kennedy, B. C., Merritt, H., Casey, J. T., Austin, M. C., & Daskivich, T. J. (2015). Progressive independence in clinical training: Perspectives of a national, multispecialty panel of residents and fellows. Journal of Graduate Medical Education, 7(4), 700–704.

    Article  Google Scholar 

  • GPSA. (2017). Managing uncertainty in general practice. Booklet produced by General Practitioner Supervisors Australia (GPSA). Bendigo VIctoria Australia.

  • Hatala, R., Ginsburg, S., Hauer, K., & Gingerich, E. (2019). Entrustment ratings in internal medicine training: Capturing meaningful supervision decisions or just another rating? Journal of General Internal Medicine, 34(5), 740–743.

    Article  Google Scholar 

  • Hauer, K. E., Cate, T., Boscardin, O., Irby, C., Iobst, D. M., & O’Sullivan, P. S. (2014). Understanding trust as an essential element of trainee supervision and learning in the workplace. Advances in Health Sciences Education Theory Practice, 19(3), 435–456.

    Google Scholar 

  • Ingham, G. (2012). Avoiding ‘consultation interruptus’ A model for the daily supervision and teaching of general practice registrars. Australian Family Physician, 41, 627–629.

    Google Scholar 

  • Ingham, G., Fry, J., & Ward, B. (2016). Adding random case analysis to direct observation (ARCADO) - Updating the external clinical teaching visit toimprove general practice registrar assessments. Australian Family Physician, 45(12), 918–920.

    Google Scholar 

  • Ingham, G., Plastow, K., Kippen, R., & White, N. (2019). Tell me if there is a problem: Safety in early general practice training. Education for Primary Care, 30(4), 212–219.

    Article  Google Scholar 

  • Kennedy, T. J. T., Lingard, L., Baker, G. R., Kitchen, L., & Regehr, G. (2007). Clinical oversight: Conceptualizing the relationship between supervision and safety. Journal of General Internal Medicine, 22(8), 1080–1085.

    Article  Google Scholar 

  • Kennedy, T. J. T., Regehr, G., Baker, G. R., & Lingard, L. (2009). Preserving professional credibility: Grounded theory study of medical trainees’ requests for clinical support. BMJ, 338, b128.

    Article  Google Scholar 

  • Leavy, P. (2014). The Oxford handbook of qualitative research. Oxford: Oxford University Press.

    Book  Google Scholar 

  • Lindlof, T. R., & Taylor, B. C. (2011). Qualitative communication research methods (3rd ed.). Thousand Oaks, CA: SAGE.

    Google Scholar 

  • Martimianakis, M., & Hafferty, F. (2016). Exploring the interstitial space between the ideal and the practised: Humanism and the hidden curriculum of system reform. Medical Education, 50(3), 278–280.

    Article  Google Scholar 

  • Melvin, L., Rassos, J., Stroud, L., & Ginsburg, S. (2020). Tensions in assessment: The realities of entrustment in internal medicine. Academic Medicine., 95(4), 609–615.

    Google Scholar 

  • Morgan, S., Wearne, S., Tapley, A., Henderson, K., Oldmeadow, C., Ball, J., … Magin, P. (2015). In-consultation information and advice-seeking by Australian GP trainees from GP trainers—a cross-sectional analysis. Education for Primary Care, 26(3), 155–165.

    Article  Google Scholar 

  • Morrison, J., Clement, T., Nestel, D., & Brown, J. (2015). Perceptions of ad hoc supervision encounters in general practice training: A qualitative interview-based study. Australian Family Physician, 44, 926–932.

    Google Scholar 

  • Neighbour, R. (2005). The inner consultation: How to develop an effective and intuitive consulting style (2nd ed.). Oxford: Radcliffe.

    Google Scholar 

  • RACGP. (2020). Becoming a GP in Australia. Royal Australian College of General Practitioners (RACGP) What is general practice? https://www.racgp.org.au/the-racgp/faculties/atsi/a-career-in-general-practice/become-a-gp. Retrieved 20 Aug 2020.

  • Reason, J. (2004). Beyond the organisational accident: The need for “error wisdom” on the frontline. Quality and Safety in Health Care, 13(suppl 2), ii28.

    Google Scholar 

  • Rizan, C., Elsey, C., Lemon, T., Grant, A., & Monrouxe, L. V. (2014). Feedback in action within bedside teaching encounters: A video ethnographic study. Medical Education, 48(9), 902–920.

    Article  Google Scholar 

  • Sagasser, M., Kramer, H., Fluit, A., Weel, W., & Vleuten, M. (2017a). Self-entrustment: How trainees’ self-regulated learning supports participation in the workplace. Advances in Health Sciences Education, 22(4), 931–949.

    Article  Google Scholar 

  • Sagasser, M. H., Fluit, C., van Weel, C., van der Vleuten, C. P. M., & Kramer, A. W. M. (2017b). How entrustment is informed by holistic judgments across time in a family medicine residency program: An ethnographic nonparticipant observational study. Academic Medicine, 92(6), 792–799.

    Article  Google Scholar 

  • Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., et al. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality & Quantity, 52(4), 1893–1907.

    Article  Google Scholar 

  • Schank, R. C., & Abelson, R. P. (1977). Scripts, plans, goals, and understanding: An inquiry into human knowledge structures. Hillsdale: L. Erlbaum Associates.

    Google Scholar 

  • Smith, C. S., Morris, M., Francovich, C., Hill, W., & Gieselman, J. (2004). A qualitative study of resident learning in ambulatory clinic. The importance of exposure to ‘breakdown’ in settings that support effective response. Advances in Health Sciences Education, 9(2), 93–105.

    Article  Google Scholar 

  • Sturman, N., Jorm, C., & Parker, M. (2020). With a grain of salt? Supervisor credibility and other factors influencing trainee decisions to seek in-consultation assistance: A focus group study of Australian general practice trainees. BMC Family Practice, 21(1), 28.

    Article  Google Scholar 

  • Szymczak, J. E. (2016). Infections and interaction rituals in the organisation: Clinician accounts of speaking up or remaining silent in the face of threats to patient safety. Sociology of Health & Illness, 38(2), 325–339.

    Article  Google Scholar 

  • ten Cate, O. (2013). Nuts and bolts of entrustable professional activities. Journal of Graduate Medical Education, 5(1), 157–158.

    Article  Google Scholar 

  • Valentine, N., Wignes, J., Benson, J., Clota, S., & Schuwirth, L. W. (2019). Entrustable professional activities for workplace assessment of general practice trainees. Medical Journal of Australia, 210(8), 354–359.

    Article  Google Scholar 

  • Wearne, S., Dornan, T., Teunissen, P. W., & Skinner, T. (2012). General practitioners as supervisors in postgraduate clinical education: An integrative review. Medical Education, 46(12), 1161–1173.

    Article  Google Scholar 

  • Wearne, S. M., Butler, L., & Jones, J. A. (2016). Educating registrars in your practice. Australian Family Physician, 45(5), 274–277.

    Google Scholar 

Download references

Acknowledgements

This research project was supported by the Royal Australian College of General Practitioners with funding from the Australian Government under the Australian General Practice Training program. We also acknowledge the support of General Practice Training Queensland with recruitment and data collection.

Author information

Authors and Affiliations

  1. Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, 8th Floor Health Sciences Building, Royal Brisbane Hospital, Herston, Brisbane, QLD, 4006, Australia

    Nancy Sturman

  2. Faculty of Medicine, The University of Queensland, Brisbane, Australia

    Malcolm Parker

  3. New South Wales Regional Health Partners, Newcastle, Australia

    Christine Jorm

Authors
  1. Nancy Sturman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Malcolm Parker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christine Jorm
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nancy Sturman.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sturman, N., Parker, M. & Jorm, C. Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning. Adv in Health Sci Educ 26, 297–311 (2021). https://doi.org/10.1007/s10459-020-09986-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10459-020-09986-7

Keywords

Search

Navigation