Family Practice Vol. 17, No. 6, 547-553
© Oxford University Press 2000
Education |
What are the characteristics of the competent general practitioner trainer?
a Department of Vocational Training for General Practice, University of Groningen,
b Director of the Department of General Practice, Faculty of Medical Sciences, University of Groningen,
c Institute for Medical Education, Faculty of Medical Sciences, University of Groningen and
d Clinical Training Centre, Faculty of Medical Sciences, University of Nijmegen, The Netherlands.
Correspondence to PM Boendermaker.
Boendermaker PM, Schuling J, Meyboom-de Jong B, Zwierstra RP and Metz JCM. What are the characteristics of the competent general practitioner trainer? Family Practice 2000; 17: 547–553.
Received 22 February 2000; Accepted 17 July 2000.
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Abstract |
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Background. Increasing attention is being given to the training of doctors to become teachers. This does not apply only to the schooling of teachers in undergraduate medical education: at the postgraduate level, general practitioner trainers (GP-trainers) receive special schooling to prepare them for their role. Yet the skills, knowledge and traits that should be expected in the competent GP-trainer have not been elucidated precisely.
Objectives. The aim of this research project is to determine the traits, knowledge and skills required for a competent GP-trainer.
Method. We used a qualitative method to answer the question. Ten focus-group meetings were held involving three Departments of Vocational Training in The Netherlands. Each group consisted of GP-trainers, GP-trainees or staff members. The transcriptions of these meetings were analysed, resulting in a description of what makes a competent GP-trainer.
Results. Five hundred items were obtained from the focus-group meetings, each of which was formulated in the form "A good GP-trainer is/can/knows ... ", etc. These items were divided into the following categories: teaching knowledge, teaching skills, teaching attitude and personality traits of the GP-trainer. A competent GP-trainer must understand basic teaching methods and be able to apply this knowledge. The skill to give good feedback was seen as an important asset for a competent GP-trainer, as were observation skills, the skill to analyse and the skill to foster reflection in the trainee. The teaching attitude of a competent GP-trainer is characterized by giving latitude to and having respect for and interest in the trainee, and being available for consultation, while the teaching approach should be individualized. Enthusiasm, flexibility, patience and self-insight were some of the personality traits identified.
Conclusion. Many characteristics were identified as a result of this research. The next logical step will involve a Delphi consensus procedure to obtain a profile of the competent GP-trainer. This profile will then be suitable in setting the standards for curricula for future GP-trainers.
Keywords. Focus groups, general practitioner trainer, qualitative research.
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Introduction |
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To become a general practitioner (GP) in The Netherlands, 3 years of training are required after graduation as a medical doctor. During this 3 years, the general practitioner trainee (GP-trainee) spends the equivalent of 4 days per week with a GP, during two periods lasting 12 months each.1 These periods are usually completed in different general practices, where the GP then acts as coach and teacher (GP-trainer).2,3 To prepare the GP-trainers for their role, they are given specialized training before and during their active role as GP-trainer from Departments of Vocational Training for General Practice.
The knowledge, skills and specific traits that make a GP-trainer competent have not been analysed. In this study, the focus is on the GP-trainer in the role of teacher. A premise is that the GP-trainer is a competent GP, but what is a competent GP-trainer?
Although a considerable amount of research has been carried out studying teachers, less research deals specifically with teachers of medicine, and almost none covers the one-on-one teaching of GP-trainees. In 1984, Durno published his ‘minimum standards for training’.4 He proposed 10 essentials for GP-trainers: enthusiasm, clinical soundness, attendence of a basic trainers' course, satisfactory premises, good records, time to teach, knowledge of general practice publications, support by partners and staff of teaching, recognition of the need for assessment and understanding of one-on-one teaching methods. Additionally, Irby (1994) states that clinical teachers should actively involve their learner, enjoy teaching, meet individual needs, be practical, relevant, selective and realistic, and provide feedback and evaluation.5 Cleave-Hogg and Benedict (1997) interviewed 14 anaesthesia teachers and identified several characteristics of good teachers, besides those already mentioned: commitment, enjoyment of one's profession, understanding oneself as a role model, motivation to upgrade and to enrich one's own learning and the ability to establish and maintain an interactive professional relationship.6
In 1998, Munro et al.7 published an article describing the use of a Delphi consensus procedure in order to determine specific key attributes of a good GP-trainer. A list of 150 characteristics was generated by a panel of eight medical education experts and from published data. Each characteristic was given an importance rating on a five-point scale by 151 participants in a Delphi consensus procedure. Thus four categories were identified by factor analysis: interpersonal relationship, professional development, personality and teaching quality. The top five most important trainer characteristics were: honesty, being available, being a good communicator, clinical soundness and taking training seriously.
In the present study, however, before using a (Delphi) consensus procedure, we made an inventory of what the characteristics for a competent GP-trainer should be, by asking GP-trainers, GP-trainees and staff members of Departments of Vocational Training the question, "What characteristics (knowledge, personal traits and skills) are necessary for a GP-trainer to be a competent trainer?"
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Methods |
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To answer this complex question, a qualitative research method, the focus-group method, was chosen, as the study was explorative and the information had to come from professionals involved in GP-training.8,9 Focus groups are the best way of gathering the maximum information on a topic about which very little is known.10 The focus-group method involves the meeting of a group of people, all of whom are involved with some aspect of GP-training. This group then has a brainstorming session based on several questions, which are formulated beforehand. The groups consist of six to 12 persons and the session is led by a group leader, the moderator, who is assigned the task of presenting the questions to the group and moderating the conversation. The moderator tries to avoid answering questions or influencing the discussion.11
The questions presented to the group in our study were the following: (i) What knowledge, skills and characteristics are required for a competent GP-trainer? (ii) What characteristics make an incompetent GP-trainer? These questions were presented to groups of GP-trainers, groups of GP-trainees and groups of staff members (of Departments of Vocational Training). In forming the focus groups, it was decided that homogeneity of the groups was very important. Increased homogeneity leads to decreased bias and inaccuracy, which may be caused by hierarchical differences within the group. In the literature, the prediction is made that using any more than three groups per segment will lead to redundancy, that is to say, that no new facts will come to light.12 We therefore chose to use three sessions per segment. The groups were selected from three different Departments of Vocational Training in The Netherlands, to avoid local bias. A group in Groningen was used as a pilot focus group to test the questions, reducing the set to the questions mentioned earlier. Focus groups were then held at each location for each of the three segments. Every session was tape recorded and later transcribed. Each session was then summarized, in the form of a number of statements, which were sent to each of the participants with a commentary form. Each participant received only the summary and statements from their own brainstorming session.
Analysis
Each of the transcriptions was analysed by the first author and an independent researcher.13 Many items were obtained. Each item consisted of a short statement summarizing a section of the transcription and was written in the form of a statement such as: "A competent GP-trainer is .../knows .../can ...", etc. Negatively formulated statements, which were especially frequent with the final question, were transformed into positive statements whenever this was possible without changing the basic meaning of the text.
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Results |
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Besides Groningen, the other two departments involved in the study (which were selected by lot) were Rotterdam and Maastricht. Although we tried to have the focus-group sessions with third-year GP-trainees in every case, this proved impossible in Rotterdam. The GP-trainee session in Rotterdam was attended by first-year GP-trainees. Since this session in Rotterdam contributed non-redundant information to the study, an additional session, including first-year GP-trainees, was held in Groningen. However, this produced redundant information. Thus 10 focus-group meetings took place between March and July of 1998 with three different moderators and 76 participants altogether. More than 500 statements resulted from the transcription analysis. During the analysis process, two researchers divided the statements into approximately 40 themes (Table 1
).
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Independently of each other, the five authors divided the themes into categories. After comparison and discussion of the categories, four categories of themes emerged for characterizing the competent GP-trainer: (i) teaching knowledge; (ii) teaching skills; (iii) teaching attitude; and (iv) personality traits. In the process of analysis, for example, the following summary statements were obtained from the group sessions: a good teacher allows their vulnerability to show; allows themselves to be observed; discusses their own mistakes; and can accept criticism. These statements can be collectively summarized under the theme: "A good teacher is open to criticism". This theme was then categorized under the heading "teaching attitude". Themes belonging to specific categories will be discussed with quotation(s) to illustrate the specific themes.
Teaching knowledge
A competent GP-trainer needs to understand different teaching methods and know when and how to apply the various methods. Knowledge about varying learning styles is a good example of this.
"Yes, knowledge or skills, I think these are absolutely required, if you don't have that, you're not starting with much ..." (GP-trainer)
"We now are taught to recognize different styles of learning. I found this quite useful." (GP-trainer)
Teaching skills
In the category of teaching skills, the use of teaching knowledge is of course very important, but giving good feedback is fundamental:
"To use this knowledge, that is a real skill. If you have the knowledge, and know it, and you don't do anything with it, yes, then you aren't bringing any grist to the mill." (GP-trainer)
"A good teacher can, wants to, and dares to give good feedback. He has to have that skill, he has to have that desire, and he has to have the courage." (GP-trainer)
Other skills that are essential for a competent teacher are observation and analysis. The GP-trainer should observe the GP-trainee with some regularity, during surgery and house calls, but also indirectly with the use of video-taped surgeries. The GP-trainer has to be able to analyse the observations, enabling him/her to give specific feedback. In addition to the day-to-day chores involved with running a practice, the GP-trainer has to be alert to deficiencies and gaps in the GP-trainee's knowledge. The GP-trainer has to have an overall picture of the GP-trainer's activities in order to properly assess the GP-trainee when he/she is seeing patients, but also outside the patient setting. This allows the GP-trainer to determine which steps in the learning process should follow for the GP-trainee.
"I find it very important that he is observant." (GP-trainee)
"He definitely needs analytical ability to be able to analyse things he sees, hears, and observes and to connect these to how the GP-trainee is functioning at different levels." (GP-trainee)
"There comes a time when you notice specific deficiencies in a GP-trainee which you can then change. In other words, you have this opportunity if you observe your trainee." (GP-trainer)
The trainer also has to teach the GP-trainee to reflect on his/her own way of thinking and managing patients.
"A teacher who has the ability to put your thought processes under a microscope, what causes you to make a certain diagnosis or to decide on a specific treatment, to allow you to reconsider your decision making process, to let you reflect, why did you do that at that time, what were the factors involved at that time? How does that work?" (GP-trainee)
There has to be open communication between the GP-trainer and the trainee. The trainer should be a good listener. If conflicts do occur, however, the trainer has to be able to deal with them.
Teaching attitude
One of the most important characteristics in this category was found to be the latitude which a trainer gives a GP-trainee to discover his/her own style and develop his/her own method of practising. The trainer should have respect for the GP-trainee, should not demean the trainee, especially not in the presence of a patient.
"You can call it respect for the other person. You have to ask yourself what kind of person this is, and what kind of GP he/she will become, and the role that you will play in that process, all the while being careful not to make a clone of yourself, because, I don't think that that is a good thing." (GP-trainer)
"You should not copy the style of the trainer." (GP-trainee)
"A competent trainer does not contradict the treatment plan of the GP-trainee without prior discussion, and certainly not in the patient's presence." (GP-trainee)
"You have to be able to take a step back. Don't always try to do everything yourself. You have to give the GP-trainee the freedom to do things which you are able to do yourself." (GP-trainer)
"That has a lot to do with that attitude, I think. If you ask me, it has to do with a curiosity about the potential GP who lives in the trainee. So it is not about making a copy of yourself, but it's about waking up the doctor who is in your GP-trainee. And yes ... awakening, bringing out, that has to do with your attitude, and giving the GP-trainee space is absolutely necessary, but this is also inherent to being a GP." (staff)
The trainer must be open to criticism about his own function.
"Oh, definitely, he has to have the courage to, for example, speak with the GP-trainee when things are not going well, and to admit that things are not going well. This courage may sometimes imply that he is prepared and willing to look at his own weaknesses. Being able to do this is a characteristic of a competent trainer." (staff)
A GP-trainer will have to be interested in the GP-trainee, to be curious about the personality of the GP-trainee, his/her norms and values, which combine to make it possible to give feedback about the GP-trainee's behaviour.
"You are interested in what goes on in a GP-trainee, what interests him/her, why does he/she find that difficult and not this ..." (GP-trainee)
"Negatively stated, if he finds the patient's history more interesting than that of the GP-trainee, then I think he's a bad GP-trainer." (staff)
"The GP trainer should be curious, ready to be surprised, something like that." (staff)
A GP-trainer has a dual responsibility. On the one hand he/she is responsible for good patient care, and on the other hand he/she is responsible for providing the GP-trainee with a good education; a situation which can potentially be quite stressful. A competent GP-trainer can cope with this.
"I agree, the tension resulting from the dichotomous role of being a GP and being a trainer, to be able to cope with that, it's bad if he is unable to do this." (staff)
"It's very important that you notice and allow mistakes made by GP-trainees and of course you don't like the fact that it's happening in your practice. And it is ... on the one hand you want to protect your patients from such mistakes, and on the other hand, it is impossible to completely avoid this, and the reverse also happens that you want to protect your GP-trainee from making mistakes. I think that, to be successful all around, that you as GP-trainer will have to expend a lot of energy." (GP-trainer)
In a one-on-one situation, the GP-trainer must be able to individualize his teaching approach to the specific GP-trainee. All GP-trainees should be approached according to their learning needs.
"... and understand that GP-trainees are not all cut from the same cloth." (staff)
"So, in other words, the GP training programme is individualized because every trainee will have a different background, and every trainee will also have different gaps in his/her knowledge. That makes tremendous demands on the GP-trainer" (GP-trainee)
The GP-trainer has to realize that he/she is a role model for the GP-trainee. This is especially important during the first period of the training period, because at this time, the GP-trainee encounters general practice and its associated threats and unknowns for the first time. The competent GP-trainer is aware of this situation, and is equally aware of his/her function as a role model.
"That is a very desirable quality that has to do with that attitude, that way you can convey something to the trainee, not by saying you have to do this, but by actually doing it. Do you follow?" (staff)
"... that you have to be an example for the GP-trainee, and that has to be interwoven throughout the training period, and uh, I think it's good to be aware of this, not continually. That's how a GP-trainee sees you, doesn't he?" (GP-trainer)
A competent trainer has to be able to provide a safe environment for the GP-trainee, an environment in which the GP-trainee can and will make mistakes and in which he/she has the feeling that he/she can experiment, while at the same time being watched over by the trainer, allowing for the type of safe environment which makes it possible to further explore relevant emotions and feelings.
"A good trainer is one who gives the trainee the room to work independently and at the same time keeps an eye on the trainee and an overall picture of what the trainee is doing." (GP-trainee)
"An education doesn't pay off until there is a good learning environment, when there is safety, when there is space ..." (GP-trainee)
"A GP-trainer has to create a safe environment for the trainee. When you start reviewing videos and those sorts of things, those are situations in which the trainee feels pretty vulnerable. He has to present you with a certain feeling of security, the possibility of observing and discussing these situations ... " (GP-trainee)
"It's also exciting, sometimes you make a decision and you wonder, uh oh, and if you then also have a trainer who has no time for you or one who gets irritated, yes, that is not a safe situation." (GP-trainee)
Personality traits
One important traits in this category is enthusiasm. The competent GP-trainer must attempt to convey his enthusiasm to the practice staff too:
"That he enjoys his profession, and can clearly convey this." (GP-trainee)
"And he has to be enthusiastic." (staff)
"To discuss being a GP-trainer with other people in his practice and make them enthusiastic, or to gauge how they feel about it." (GP-trainee)
A good GP-trainer has self-insight, self-knowledge and the ability to reflect on situations and actions: this is a basic prerequisite, which also allows the trainer to put the attitude and behaviour of the GP-trainee in perspective.
"... You have to be conscious of those sorts of things, and you have to be able to say ‘I want this but I don't want to convey that to you', or you realize that I do it for such-and-such a reason while it is possible to do it another way, so I think that you have to have a kind of bird's eye view of your own role before you can give someone else feedback." (GP-trainer)
"Well, I think that it's a very important characteristic that someone is able to reflect upon their own situation, I think you really need that to be able to dedicate yourself to someone else. So you have to be comfortable in your position. I think that that's very important." (GP-trainer)
Flexibility is a characteristic which most GPs have. This notwithstanding, it is a trait which is particularly drawn upon in a GP-trainer.
"Such a GP [trainer] therefore has to be very flexible, he must be able to handle interruptions at all times during the day." (GP-trainee)
Integrity was mentioned in each group as a trait which a competent GP-trainer should have. Besides integrity as a personality trait, it also appears important that the desire to be a GP-trainer is internally motivated, that is to say, that he/she is not motivated by material or non-material benefits.
"Well, maybe I can take that one step further, and want to say that somebody who cheats in that respect, and who defrauds the system in other respects, and then I ask myself whether or not he/she takes his/ her role as teacher seriously." (staff)
"If, for example, the GP-trainee is used for other things, secretarial duties or for getting coffee, that, I don't know. Or to keep a 4000 man practice running. Or to let the dog out. Or to treat drop-in patients during holidays. Yes, that is a little bit unrealistic, eh." (staff)
A summary of all the results gives a complete picture of the competent GP-trainer. Of course, if all these characteristics are combined, we end up with an unrealistic concept of what a GP-trainer should be, and sometimes even a somewhat idealized representation.
"Then you get a sort of superman ... a calm, well structured trainer with good introspective abilities who maintains an overall picture and for me that is about the most ideal representation." (GP-trainee)
"Yes, for me a trainer is also ... would actually have to be a special person, more even than a GP, a GP-trainer would have to be a kind of super-human." (GP-trainee)
"... and this demands a certain degree of TLC on the part of the GP-trainer ... you could say that the trainer forms a foundation upon which the trainee can build his education." (staff)
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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As a result of this research, an image of the ideal GP-trainer has developed. A competent trainer needs good teaching knowledge. This was not examined in any great depth by the participants of the focus groups, but it was clear that knowledge about the skills was implicitly assumed. The fact that there must also be knowledge about adult learning and learning theories (i.e. about different learning styles) was raised, but we decided not to separate this (implicit and explicit) knowledge into individual themes. With the help of knowledge, which can also partially be obtained through experience with teaching, it is possible to use specific teaching skills effectively. Much of the current curriculum for GP-trainers focuses on these teaching skills, possibly because these skills appear at a glance to be easier to teach, assess for, and otherwise objectify.
Teaching attitude includes aspects of the teaching process which determine the quality of the teaching relationship between the GP-trainee and the GP-trainer. An important theme in this category appears to be the space which a GP-trainee requires to develop into a GP with his/her own style. A particular problem for the GP-trainer is that he/she has to be able to cope with the tension that may result from the combination of his role as a GP and the responsibility for his relationship with his/her patients and his role as teacher. The GP-trainer is regarded as a role model by the GP-trainee, which is a part of the apprenticeship, and he/she must be aware of the fact that his/her actions, as well as his/her words, will be scrutinized and duplicated by the GP-trainee.
The personality traits that have been mentioned are important for any GP, except for enthusiasm, which is particularly associated with a GP's functioning as a competent trainer. The ability to reflect and self-insight will be even more important for a GP-trainer than for a GP, he/she must also be able to reflect upon his/her role as a teacher. The major difference between the criteria for teaching attitude and personality traits is the fact that the themes in the ‘personality traits’ category are independent of the presence of a GP-trainee.
The focus-group method used for this research project was appropriate for determining the personality traits, knowledge and skills of the competent GP-trainer. The redundancy that we expected after interviewing three groups was indeed seen. A large amount of information was obtained from the discussions, which was readily analysed. A snapshot view of the competent GP-trainer in The Netherlands of 1998 has been obtained. Keeping this restriction in mind, it is none the less possible to draw a number of conclusions. Despite the different categorization of the themes, the results were supported by Munro et al.7 Grouping the themes into categories gives an overall picture of aspects of the teaching disposition. In fact, with this grouping, which follows from groupings that have existed for much longer for teaching objectives, a base has been created for the translation of teaching aspects into teaching objectives for GP-trainers.14
As a result of this research, an image of the ideal GP-trainer has developed. This image now has to be translated into a realistic profile which will serve as the ultimate goal for the schooling of GPs and as a starting point for assessment. On the basis of the research model, this collection of teaching characteristics wil be weighted and consolidated into the profile of the ideal GP-trainer. A Delphi consensus procedure has been initiated with this purpose in mind.
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Acknowledgments |
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The authors gratefully acknowledge the moderators Albert Scherpbier, Ivo Heij, and Henk Goettsch, Edwin Schippers and all the participants of the focus groups.
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References |
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