3.6.1 Division of Labour
The Australian literature appears to suggest that the best model is one where one teacher operates across all the different levels of learner (Laurence et al., 2011). In the UK, this same arrangement can exist but it is also common for different GPs in the practice to lead on different parts of the collective teaching program. This model can help share the teaching workload but might also
contribute to the fragmentation within our system. To explore this, practices where one GP leads on all teaching, as well as practices where teaching is distributed between GPs within the team were represented in this thesis (see 5.4). Regardless of the model employed, there is a lack of evidence on the impact of integrated teaching roles on both the quality and quantity of education delivered.
3.6.2 Leadership of Teaching and Additional Skills Required
Effective leadership from the GP is key to providing high quality teaching, and management of VI teaching requires further skills than those required for teaching SLL (Thomson et al., 2014). GPs will have different requirements and expectations for each of their supervisory roles, both from external institutions but also from the learners themselves (Cotton et al., 2009; Harding et al., 2011). A greater level of organisation is then required to negotiate these different learning needs across a range of teaching activities (Ahern et al., 2013; O’Regan, Culhane, Dunne, Griffin, Meagher, et al., 2013).
Van de Mortel et al (2013) reports that GPs need to have oversight of all
teaching activities in the practice. Although they may delegate a teaching task, they retain responsibility for the coordination of teaching. The use of shared learning activities, such as small group teaching, requires GPs to possess group facilitation skills and may require them to manage group dynamics and
multilevel teaching sessions to avoid timetable clashes, and hence exclusion of individuals, can be challenging. Shared learning will be further discussed in 3.8. In the only published study giving the views of the educational bodies, this need for additional skills is recognised. In 2011, Stocks et al (2011) interviewed all seventeen Australian Regional Training Providers (RTPs) regarding VI in their programmes. At that time, just under a third of areas had actively developed VI, while another third were in the early stages of promoting this. Only three of the RTPs had actively collaborated with their local university to coordinate activities across the continuum. An important finding was their recognition of the need to develop a formalised programme to support GPs and practices to manage VI. This aligns with learners’ and supervisors’ perceptions that additional skills and organisation are required. Given that this study was published six years ago, it would be helpful to know to know how VI had progressed since then and if it had not, why this has not happened.
3.6.3 The Tools of Teaching
A number of different teaching methods are utilised by GPs teaching in practice (see Table 3-2). With the choice of Activity Theory as a conceptual framework for this thesis, these will be referred to as tools which can be used to enable the activity of teaching (see 4.3). In this section, these tools are described, as well as the possible implications of utilising these in a VI teaching context. With the exception of shared learning and near peer teaching, a limitation of the majority of the research on these teaching methods is that it is mainly descriptive rather than analytical which therefore limits assessment of its educational value
(Bordage & Harris, 2011).
3.6.3.1 Teaching on the Run
Teaching on the run describes the weaving of teaching through and between clinical encounters (Catchpole, Albert, Lake, & Brown, 2005). Multi-tasking in this way would be more complex and potentially more stressful when more than one learner is involved. A challenge would be maintaining high quality clinical care while addressing learners’ educational needs.
3.6.3.2 GP Grand Rounds
GP grand rounds, based on a hospital model, are promoted as a way to take teaching one step back from direct clinical care through presentation of clinical cases (Anderson & Thomson, 2009). An initiative in Australia where a teaching practice hosts monthly meetings for local teaching practices in partnership with a GP academic is described but not evaluated. Given recent debates on the educational value of grand rounds (Sandal, Iannuzzi, & Knohl, 2013), it would be prudent to evaluate this further before widespread adoption is encouraged 3.6.3.3 Remote supervision
Remote supervision is used in Australia to provide distance education to GP registrars providing care to remote and rural communities in Australia (RVTS, 2016). These trainees choose to work in a remote and rural context and possibly are different to standard GP trainees. Therefore, they may be more suitable for remote supervision (Wearne, 2005). In the UK, as GPSTs progress through
training, their level of supervision is tailored to their level of competence and they may work without onsite supervision. However, they would be expected to have access to immediate advice and a supervisor would be expected to be able to attend if required. Given the geographical differences between the UK and Australia, trainees in Australia may not have access to the same face-to-face support that would be expected in the UK. Therefore, Australian trainers could support multiple disparate learners simultaneously.
3.6.3.4 Wave and Parallel Consulting
Wave or parallel consulting methods involve structuring learners’ and their supervisors’ consulting to facilitate learning and feedback. The terms wave
consulting, parallel consulting and preceptor consulting are used
interchangeably in the literature (Lake & Vickery, 2006; Tran et al., 2012; Walters, Worley, Prideaux, & Lange, 2008). These all refer to techniques which are different to traditional “sitting in” or “co-consulting” and for the purpose of this thesis these will all be referred to as parallel consulting.
In parallel consulting, the GP and the learner are booked to consult individually but would meet at planned regular intervals so that the learner could present each new patient to their supervisor (Lake & Vickery, 2006). More experienced learners will usually only seek advice when needed and will convene with their supervisor at the end of a surgery for a debrief. Several Australian studies have looked at the impact of parallel consulting on the consultation and they have shown it does not negatively affect patients’ perceptions of the quality of the consultation or consultation length (Tran et al., 2012; Walters, Prideaux, Worley, Greenhill, & Rolfe, 2009; Walters et al., 2008). Walters et al (2009) found parallel consulting altered the relative time supervisors allocate to each of the tasks of the consultation. When parallel consulting, GPs spent more time on history taking and verifying the learner’s diagnostic process, and less time on examination, management and consultation administration. The above studies were conducted with supervisors supervising a single learner so similar work could be undertaken for GPs supervising multiple learners consulting
simultaneously. 3.6.3.5 ‘Sitting in’
In “sitting in”, where the learner is present in the consulting room at all times, a learner’s role may vary from being an observer to a more active participant in the consultation e.g. undertaking history taking or examination under direct supervision or responding to questions on likely diagnoses and suitable
management plans (Price, Spencer, & Walker, 2008). There are no descriptions in the literature of MLL “sitting in” concomitantly and it is unlikely that this would be recommended because of practical and patient considerations.
3.6.3.6 Online training
Increasingly, online training is promoted to help increase teaching capacity. While it is often seen as a quick fix for capacity issues, it has also been demonstrated to be a useful adjunct to enhance the learning gained from placements (Grace & O ’Neil 2014). Tools such as podcasting, e-portfolios, e- assessment, blogs, wikis and online case scenarios are becoming more common in health professions education and can be used to engage with multiple
learners, both co-located and more dispersed. The challenge is ensuring that online learning complements, rather than replaces, experiential learning and, as new tools are designed, they must be evaluated for educational impact (Zehry, Halder, & Theodosiou, 2011).