Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
Isolation, flexibility and change in vocational training for general practice: personal and educational problems experienced by general practice registrars in Australia
a General Practice and Rural Medicine, b Rural Health and Workforce Research Unit and c School of Medicine, James Cook University, Townsville, Queensland 4811, Australia
E-mail: sarah.larkins{at}jcu.edu.au
Received 15 January 2004; Accepted 17 May 2004.
Larkins SL, Spillman M, Parison J, Hays RB, Vanlint J and Veitch C. Isolation, flexibility and change in vocational training for general practice: personal and educational problems experienced by general practice registrars in Australia. Family Practice 2004; 21: 559–566.
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Abstract |
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Background. GP registrars, in common with other doctors, frequently experience high levels of stress; however, little is known about the nature and outcomes of personal and educational problems experienced during vocational training for general practice.
Objectives. The purpose of our study was to elicit the nature, causes and effects of more severe problems experienced during vocational training for general practice from the registrar's viewpoint and put these into the context of their personal circumstances and background.
Methods. This qualitative study used detailed semi-structured telephone interviews with a selected subgroup of 33 of the 1999 entry cohort of general practice registrars in Australia who had reported serious self-defined problems during an earlier longitudinal questionnaire study. Registrars were asked about the nature, antecedents and outcomes of problems experienced during GP training, actions taken to resolve the problem, and their perceptions of what might have helped prevent or minimize the problem.
Results. Problems reported by registrars fell into five major themes: isolation (structural isolation, social isolation and professional isolation); flexibility and choice (administrative issues and balancing work with personal life); change and uncertainty (within general practice and training, intergenerational changes); teaching problems; and work conditions. Actions taken and effects of problems are also discussed in the light of workforce imperatives. Results have been used to develop a list of suggestions for the providers of general practice training.
Conclusions. Registrars commonly experience problems during vocational training. These may be related to structural, social and professional isolation, or a lack of flexibility in training arrangements and balancing work and other commitments. Some of these problems may be amenable to relatively simple solutions involving term placements, selection of training practices and administrative adjustments.
Keywords. Doctors in training general practice, stress, vocational training.
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Introduction |
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Doctors frequently have poor psychological health,1 perhaps as a result of a combination of inherent personality variables and the inevitable daily stressors involved in the practice of medicine. Doctors in training are likely to experience additional stress caused by having to combine clinical practice demands and participation in training.2 Stress may be even greater in general practice training, as registrars are inexperienced in general practice and yet may have to shoulder a greater burden of clinical responsibility than hospital residents (for a review, see Larkins et al.4). In the UK, the most potent sources of stress for GP registrars are family/job conflicts, studying for the Royal College of General Practitioners Membership Examination, unrealistic expectations from patients and disruption to social life.3
GP registrars, in common with many young adults, are at a stage of life when they may be establishing permanent relationships or starting families. Australian general practice training requires registrars to change practice, and frequently relocate, as often as every 6 months, during a 3 or 4 year training period. This creates strong competitive demands that are difficult to balance. The training and professional environment is also changing. Vocational GP training and summative assessment via a certification examination have been compulsory for unsupervised practice since 1995. In response to a worsening workforce distribution, registrars were required to undertake at least some training in a rural community. In 2002, control of the training programme also changed from the Royal Australian College of General Practitioners (RACGP) to a newly formed incorporated body called General Practice Education and Training (GPET). Although educational requirements are basically unchanged, training is now devolved to evolving regional consortia of training providers, including representatives from the RACGP, the Australian College of Rural and Remote Medicine (ACRRM), local universities, divisions of general practice, and representatives of registrars and GP supervisors. This transitional period has resulted in considerable uncertainty for current and prospective registrars and training providers alike.
We explored the incidence and nature of problems experienced by Australian GP registrars through a longitudinal cohort study of the 1999 entry cohort of registrars, using annual questionnaires assessing the incidence and nature of personal and educational problems during vocational training.4,5 This paper reports a nested study aiming to characterize the more severe problems experienced by registrars during vocational training by means of in depth semi-structured telephone interviews.
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Methods |
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Participants and setting
Our longitudinal questionnaire study, reported elsewhere, revealed a high prevalence of problems during general practice training, and provided an overview of the issues involved.5 In order to explore these issues in more depth, a subgroup of participating registrars with more severe problems were invited to participate in semi-structured interviews.
Sampling
A total of 125 out of 217 (57.6%) participating registrars in year 2 (2000) of the longitudinal study reported problems (out of a total potential cohort of 400 registrars). Eighty-two of these 125 registrars were invited to interview, based on the number, range and severity of problems they reported. The aim was to perform interviews with 
30 registrars reporting a wide range of more complex problems.
Sixty-one of these 82 registrars (74%) responded, and 33 consented to be interviewed and became our sample, whilst 27 declined and one was uncontactable. The median age of interviewees was 30 years (range 27 to the late 40s), and the gender balance was 25 female (76%) and eight male (24%). Twenty-four of those interviewed had a partner, of whom 11 were also doctors. Six had children and another was pregnant.
The interview group was representative in age of all 82 registrars identified with severe problems, and the overall participating registrar cohort. Males were slightly under-represented in the interview group, compared with those with severe problems (22 out of 82; 27%) and participants in the questionnaires (34.9% male). There was no significant difference in either age or gender between registrars reporting and not reporting problems in the questionnaire study.
Collection of data
A semi-structured interview proforma was constructed using information gathered from the questionnaire study. Information was requested about satisfaction with general practice and with the training programme, problems experienced, their antecedents, actions taken and outcomes, and the registrar's beliefs about what may have helped to prevent or minimize the problems. The impact of the problem personally and professionally on the registrar and their family was also discussed. The interview was piloted on three recent graduates of the training programme.
Analysis
All 33 semi-structured telephone interviews were performed in a standardized manner (by MS), audio-taped, transcribed after removal of any identifying information, returned to registrars for approval and then coded and analysed (by JP and SL) using QSR N5 software.6 We used qualitative methods and an inductive approach to describe and explain key issues as they emerged from the data. Hypotheses were developed from the ground up rather than being defined at an early stage. The initial coding schema was developed from information in the questionnaires, then modified and expanded using sequential analysis to take into account richer information from interviews. Three interviews initially were coded independently by two researchers (JP and SL), demonstrating a high degree of concurrence.
Analysis then occurred within and between the developed categories, and additional overarching themes were recognized. Regrouping occurred under these themes using an axial coding approach.7 Validation of conclusions occurred by triangulation with data from questionnaires and from the literature.8
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Results |
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Overall, most registrars were very satisfied with general practice as a career, and 22 out of 33 registrars, despite having experienced problems, were largely satisfied with the training programme organization, citing good supervision and support as key features. Twenty registrars felt that the training programme had met their educational needs, and 15 felt that it had met their personal needs.
The axial coding process produced five common overarching themes for the problems reported. These were categorized as relating to isolation (structural isolation, social isolation in rural terms and professional isolation), flexibility and choice (administrative issues and balancing work and family), uncertainty and change (change from hospital to general practice, changes in location, changing ‘goal posts’), teaching issues and work conditions (Box 1). Although flexibility and isolation were both reported frequently, this article focuses primarily on problems involving different facets of isolation, as these may have been less recognized previously.
BOX 1 Overarching themes and categories of problems described
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Isolation
Three main facets of isolation experienced in general practice emerged from registrars' responses. Frequently, all three types of isolation were experienced concurrently. Possibly the most novel was the structural isolation of general practice. Registrars found that the physical layout of many practices together with increasing computerization discouraged contact and communication between staff members within the practices. This was seen as a contrast to the perceived team approach within the hospital system.
"... in general practice it's hard because you shut the door and you're in the room ... and you could be that way for 40 years, practising, and be stressed and horrible and depressed the whole time and no-one else needs to know.""I found it unbelievably stressful starting in general practice ... country GP [was] always what I wanted to do. Got there—and I was shocked to find that I found it terrifying, isolating, extremely isolating...Just to have gone from a setting where you were working with colleagues constantly ... so GP work is a big change. Sitting in one room."
"...in the hospital environment you're protected, you've got heaps of people looking over your shoulder. But in general practice, it is you and the patient and the door is closed."
This isolation seemed to be entrenched within some training practices, reinforcing a perception of poor support.
"Generally the atmosphere was fairly like unsupported—I had the comment made to me when I arrived, ‘Oh, the registrar just generally battles away in that back room and if they're really in dire needs they come and ask one of us’, and I just felt that wasn't very encouraging."
Whilst structural isolation was a problem for registrars in both urban and rural placements, social isolation was primarily an issue for registrars during rural rotations. This often involved settling in to a new town and house, a new job (frequently a first experience of general practice) and all accomplished in the absence of usual support structures.
"When you're so tired and you're a bit time short you don't have time for other friends or family. They all fall by the wayside and ... there's not many people around."
The length of time required to form relationships or feel accepted in rural areas, especially for highly visible young professionals, was a major issue, and it was felt that practice staff and GP supervisors had an important role in facilitating registrars' social integration.
Professional isolation was also more commonly an issue during rural rotations, particularly concerning supervision and back-up arrangements, and a perception that the GP supervisor was too busy to be interrupted.
"[The supervisor] often went away and didn't organize adequate cover."
Conversely, registrars were appreciative of supervisors who were supportive and accessible. The importance of collegiate support for debriefing was raised as an important mitigating factor for registrars in rural terms against social and professional isolation.
Flexibility and choice
Flexibility and choice in training for general practice was a major issue for the majority of registrars in the interview study. Problems with selection, availability and timing of terms, communication and guidelines, and administrative procedures were commonplace, with the major concern being a lack of responsiveness to the needs of individual registrars.
"Sometimes you feel like a baby being squeezed down the birth canal. It doesn't have any other choice."
Flexibility to balance one's own training with occupational or personal requirements of partner or family was often felt to be lacking, and registrars felt they had little choice in this area, especially when it came to rural terms.
"It's really frustrating when I'm about to turn 30, my husband's 30 and you're still being dictated where you can go to and what you can do and what you can practise.""... the main thing was moving and leaving the family. I mean that's really had a lot of implications for my wife, my daughter, which took probably another six months to rectify down the track."
Issues with flexibility and choice were more a problem in larger training programmes, and it was recognized that the administrative task of meeting registrar needs with the resources available was complex. Early in training, registrars also described problems with identifying the appropriate person to speak to about concerns. In the eyes of registrars, the most suitable people were either involved in their assessment or difficult to contact. It was felt that an ongoing relationship with a local, knowledgeable and interested medical educator throughout the period of training would be helpful.
Uncertainty and change
The change from hospital work to general practice was difficult to negotiate for some registrars. Increased responsibility, time constraints, a decrease in teamwork and contact with colleagues, and a perceived lack of preparedness for clinical presentations were some of the major challenges.
"There is a whole lot of difference between the hospital patient, and the hospital environment and general practice. There is no comparison. There is a different atmosphere and different expectations."
Political change and training uncertainties caused problems for other registrars, as did frequent changes of location and practice.
"I really feel sorry for the people that are starting the Training Program now ... It's so uncertain... I think it's awful.""Feels like we've been sold out to the Government and it's trying to fix their problem by sending, forcing people to go rural."
"I dislike the constant changing ... I don't like moving on every six months and starting over afresh all the time. I found it quite disruptive—and the patients didn't like it either."
Teaching and work conditions
Inadequate teaching time was raised as an issue by many registrars in this study, and at times the content and structure of the teaching provided was problematic. Registrars in general practice are highly motivated to learn from their more experienced supervisors, and value whatever guidance they are given. Interestingly, the registrars felt quite powerless in terms of enforcing their allocated requirements for teaching time within the practice. They felt that the training programme should have a larger role in first selecting those supervisors and practices with a genuine interest in teaching, and secondly in policing the provision of adequate teaching time and environments.
"... everyone is encouraged to [tell the college] that you're not getting your training, but it puts a lot of pressure on a basic trainee, who's in their first job in general practice to go and basically ‘dob’ on their supervisor. People then imagine it will make your work environment unpleasant."
This powerlessness extended to the negotiation of terms and conditions, especially for the first general practice term. Workload issues were important, particularly in hospital terms and rural rotations, and enforcing a limited number of patients for new registrars for as long as was necessary was recommended.
Effects of problems and actions taken
Thirty-two out of 33 registrars reported a medium or strong negative effect of the problem on their psychological health–most were non-specific anxiety and stress symptoms but some had diagnosed affective disorders.
"I had to quit the term early because I became really depressed, and I've had to start antidepressants, because of that.""... you're by yourself somewhere in the country and little issues become quite big. Because there's obviously no buffer structure around you."
In addition, some registrars reported significant psychological consequences of their problem for partners and children, and physical health effects on themselves. The problems frequently had an impact in terms of professional confidence and career plans. Many registrars described limiting their work hours, combining general practice with other fields of work, or changing their plans away from rural general practice as a result of negative experiences. Most registrars dealt with their problems by discussing them with training programme staff, whilst others sought counselling or help from their GP, relied on the support of family or friends, or used self-help strategies.
Suggestions to minimize or prevent problems
Registrars had a range of suggestions to minimize or reduce problems in future. Many suggestions that could be easily implemented were administrative changes, whilst other suggestions related to rural terms, teaching practices and some related to systemic changes.
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Discussion |
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This project, in conjunction with the related quantitative longitudinal study,4,5 had the strength of using both quantitative and qualitative methods and a longitudinal design to follow a cohort of GP registrars as they progressed through the Australian GP training programme. Strong similarities between findings of the questionnaire and interview studies and the literature (for a review, see Larkins et al.4) were found, increasing the likelihood that our findings are valid. There are clearly recognized limitations with our methods of collecting data–the definition of a problem was deliberately left open, as we wanted to study problems as defined by registrars rather than by others. The interviews reported here are from a subgroup of registrars intentionally selected for having experienced problems at the more severe end of the spectrum, and males were under-represented. It is possible that the findings may not be generalizable to registrars with no problems, or more minor issues.
It was felt that supervisors and other practice staff had a potentially very important role in mitigating isolation and facilitating the social introduction of the registrar into a new town. Low perceived emotional support from home and workmates previously has been associated with a higher chance of experiencing psychological distress,9 so this may also help minimize problems. Registrars stressed the role of peer support (preferably face-to-face) through educational releases as important, and this support appeared to be particularly critical early in training.
Decreased work satisfaction has been related to a perception of lack of control over the work environment.10 GP registrars may have more autonomy than medical students, but much less than most adults of their age, with the imposition of timing, sequencing and location of training terms. Maximizing flexibility and choice within the training programme may ameliorate some known stressors, and increase work satisfaction.
Although none of the registrars interviewed resigned during vocational training or had other very serious outcomes, a number reported considerable psychological morbidity. In addition, stress and problems for partners and other family members were commonly reported. Stressors impacting on the partners of GPs have been described previously in small qualitative studies;11 however, these fail to take into account the added significant stressor during training in Australia of frequent imposed changes of location, with the attendant difficulties in balancing the requirements of the GP and their partner. As found in other studies,12 problems frequently had an effect in terms of future career plans, with many registrars moving away from rural practice and decreasing their work hours. This has implications in terms of workforce projections, and it seems likely that acting to reduce problems experienced by registrars may have an impact in terms of addressing workforce shortages. Outcomes of problems in terms of patient care are less clearly described. Although we had few critical clinical incidents reported to us, previous descriptive self-report studies suggest that clinical performance may be negatively affected by experiencing a training problem.13
Implications for general practice training
Medical careers require several stages of education and training, and vocational training requires registrars to relocate, sometimes several times, at a stage in life when permanent relationships are often established (especially with the increase in postgraduate medical courses). These stressors previously have been regarded as largely the domain of female doctors,14 but this study suggests that both male and female registrars feel such pressures. It remains to be seen how male registrars will alter their work patterns in response. Hence, although registrars in this study perceive the current state of transition and uncertainty in GP training as a negative development, it is also an opportunity for redesigning some aspects of training.
Although all stressors impact on an individual, the extent to which they cause psychological impairment may depend on mediating variables such as personal characteristics and the degree of social support available.9,15 The results of this study suggest that it is imperative to view registrars and their family (and in some cases friends) as a total unit, as problems experienced are closely interconnected between these groups. We developed a model that may explain the effects of stressors on registrars during training for general practice.
Figure 1 depicts how training programme stressors (e.g. high workload, rural terms and exams) and personal stressors (relationship problems or illness) can impact on the combined unit of registrar and their supports. However, usually family supports act as a buffer, protecting the registrar from some stress. Other mediating variables such as perceived support available (socially, from peers or from the training programme) and individual personality differences have an effect on the outcomes. Personal outcomes include problems with physical or psychological health (for registrar or partner) or relationship issues, and these interact strongly with professional outcomes, including work satisfaction, enthusiasm, performance, workforce participation and probably rural retention.
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Figure 2 depicts the situation when the registrar is removed from their usual support structures, losing many buffers against the stressors of practice (increased workload and professional isolation of rural practice, relationship problems from separation). It is therefore not surprising that more negative outcomes may result, contributing to poorer health of the registrar, lower workforce participation and rural retention, and probably worse clinical performance.16 Given the many complaints about the compulsory and inflexible nature of rural terms, it would seem appropriate to challenge the necessity for mandating rural terms for all registrars, especially for those with no interest in rural practice. This study suggests that imposing a rural term on those with no interest actually decreases their enthusiasm for rural general practice and, although it appears to meet a short-term workforce need, it certainly does little to address longer term workforce problems. It may be more productive to ensure that registrars who choose to undertake rural training have a productive and well-supported experience. It is imperative to consider the needs of spouses for relevant employment, childcare requirements and suitable housing for the family. Funded trips to meet with other registrars for face-to-face education and peer support are important, as is adequate financial support in the forms of accommodation and relocation assistance.
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A key principle in the reorganization of GP training in Australia has been the devolution of training responsibility to a larger number of smaller providers with defined geographical boundaries. Such regionalization potentially may result in improved communication between registrars and providers, although it is likely to be more expensive on a national scale. Financial limitations and the economies of scale must be balanced against the imperative of responsiveness to individual needs, and more discussion is needed about the optimal size of organizational units. Medium size units in provincial centres with teaching posts in surrounding towns may provide some balance between these two competing needs.
A list of strategies for training providers was developed on the basis of study responses, aimed at minimizing problems for future GP registrars (Box 2).
| BOX 2 Suggestions to minimize problems during GP training Term placements
Training practices
Administrative
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Conclusions
Registrars in general practice, like doctors in training elsewhere, commonly experience problems during vocational training and need support. In Australia, problems are commonly related to a sense of isolation and lack of flexibility, and can occur in rural or urban placements, although sequelae may be more severe with family separation in rural terms. The political imperative of rural workforce shortages has been a major factor in the restructuring of general practice training. It is essential that the needs of junior doctors in terms of support and flexibility are not overlooked in this process. Relatively simple administrative and structural strategies may help to ameliorate some problems experienced by doctors during vocational training. Addressing problems experienced by GP registrars during training may have implications in terms of workforce and rural retention.
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Declaration |
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Funding: The initial 3 year study was funded by the RACGP, and the interview study was funded by the School of Medicine, James Cook University and the North Queensland Subfaculty of the RACGP.
Ethical Approval: The project was approved by the Research Evaluation and Ethics Committee (REEC) of the Royal Australian College of General Practitioners (RACGP) (approval number 98/35) and undertaken with the full support of the General Practice Registrars' Association (GPRA).
Conflicts of interest: S.L. was a general practice registrar during much of the study.
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Acknowledgments |
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We wish to thank Mr Justin Spillman for graphics support, Ms Candy Wilson and Ms Debbie Colledge for transcription, and Dr Jane Harte for assistance with validating the registrar selection process.
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References |
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