GP Supervision:
Understand & MinimiseYour Risks
GP Supervisors Australia
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About GPSA
GPSA is the national representative body that unites GP Supervisors by
promoting recognition for supervision work through
open and accountable advocacy.
“We are the voice of GP Supervision making the next generation of family doctors”
“We are making GP Supervision rewarding, respected and recognised”
“We are working to recruit and retain quality supervisors”
- Advocate for Supervisors with relevant health sector policy makers, & Govt.
- Work with and listen to, and support our members
- Negotiate the National Terms and Conditions between Supervisors and Registrars on
behalf of Supervisors
Moderator:
Dr. Patricia Baker Chair of GPSA
• GAICD MBBS FRACGP
• Chair GP Supervisors Australia
• Principal Keperra Family Practice, QLD
• Board North Brisbane Medicare Local & QLD
Faculty Board RACGP
• Strong background in medical boards and
organisations.
• Interest in indigenous and preventative
health as well as health education
Guest Presenter: Ms. Julie Brooke Cowden
Claims Manager (Solicitor) MDA National
•
BSc & BLaws (LLB) Macquarie University; Master Laws (LLM) Sydney 2005.
•
Specialist Accreditation in Personal Injury (Defendant) Litigation, 2000
•
Adjunct Lecturer with the University of Notre Dame Australia’s School of Medicine in Sydney
•
Member Concord Repatriation General Hospital’s Human Research Ethics Committee 10 years
•
Specialised work with Doctors on:
•
Complaints
•
Claims
•
Performance & disciplinary issues
•
Conduct and health matters
•
Medicare investigations & audits
•
Pharmaceutical Services investigations
•
Coronial investigations & inquests
Guest Observer: The Hon. Senator Fiona Nash
• Elected to the Australian Senate in 2004,
• Since 1 July 2005 for the Nationals, NSW
• Assistant Minister for Health
• Interests: education, health, food security
to safe environmental practices
• Deputy Leader of the Nationals in the Senate, with party
experience as branch chairman, state executive, delegate to
Federal Council, and National Party Whip in the Senate
• Bachelor of Arts (Liberal Studies) Mitchell College, Bathurst
Outline
• Definition, role and responsibilities of the GP
Supervisor
• General knowledge questions
• Issues relating to GP Supervision
• When things go wrong – case scenarios
• Risk management measures
• Checklist
• Q &A
Definitions
“A GP Supervisor is a General
Practitioner who establishes and
maintains an educational alliance that
supports the clinical, educational and
personal development of a Registrar”
Wearne et al 2012
Definitions
• In a general practice setting, a GP Supervisor may be
supervising:
– Medical students
– Prevocational doctors doing general practice terms
e.g. PGPPP
– GP Registrars
– IMGs working towards a Fellowship in General
Practice who are not on a Registrar training program
What do Effective GP Supervisors Do?
“… promote reflection and give feedback based on direct
observation to facilitate clinical deliberate practice”
“… attend to the Registrar’s wellbeing and make it safe for the
registrar to reveal and address the weaknesses in his or her
knowledge, skills and emotional responses to practice”
Wearne et al 2012 p1169
GP Supervisor’s Interconnected Roles
Summarise learning
Organise learning
environment
Attend to Registrar’s
wellbeing
Be an expert clinician
Ensure patient safety
Monitor learning
process
Monitor Registrar’s
learning
Adapted from Wearne et al 2012 Medical Education p1167
Assess Registrar’s
learning needs
Facilitate learning:
• Give resources
• Promote reflection
• Give feedback
• Model behaviour
Responsibilities of the GP Supervisor
• Discuss the supervised doctor’s role & responsibilities
• Clarify the supervised doctor’s skill level & abilities
• Establish triggers & guidelines
– confirm when the supervised doctor must seek
advice and/or assistance
• Ensure that feedback is regularly provided & encourage
ongoing dialogue
• Develop strategies to minimise risk
• Recognise and manage conflict & other problems early
Expectations of the Medical Board
The Medical Board of Australia’s (MBA) Good
medical practice- a code of conduct for doctors
in Australia states that good medical practice,
with regard to teaching and supervising,
involves:
– 10.2.1: Seeking to develop the skills, attitudes
and practices of an effective teacher, whenever
you are involved in teaching
– 10.2.2: Making sure that any doctor or medical
student for whose supervision you are responsible
receives adequate oversight and feedback
Expectations of the Medical Board
In relation to assessing colleagues, the MBA’s
code of conduct notes that in order to achieve
the highest standards of practice, doctors
should:
– 10.3.1: Be honest, objective and constructive
when assessing the performance of colleagues,
including students. Patients will be put at risk if
you describe as competent someone who is not
Expectations of the Medical Board
Finally, the MBA’s code of conduct provides guidance
specifically with respect to medical students. It is
suggested that supervising doctors:
– 10.4.1 Treat students with respect and patience
– 10.4.2 Make the scope of the student’s role in patient care
clear to the student, to patients and to other members of
the healthcare team
– 10.4.3 Inform patients about the involvement of medical
students, obtaining their consent for student
participation, while respecting their right to choose not to
consent
GP Supervision – General Knowledge Questions
Quiz and discussion
1. Apart from appropriate professional indemnity
insurance, are there any other insurance
requirements for those working as GP Supervisors
(on site or remotely)?
A. Yes, notification in writing is required
and extra premium payable
B. Yes, notification in writing is required
but no extra premium payable
C. No
D. Only if doing remote supervision
Answer = C
2. Are supervised doctors (on Registrar policies)
covered to perform a procedure their supervisor/s is
not covered to perform?
A. Yes
B. No
C. Only if the Registrar is directly
supervised (observed) whenever the
procedure is performed
D. Only if the Registrar has previously
obtained qualifications, skills and
training in the procedure
Answer = B
3. Are GP Supervisors legally liable for what their
Registrars do?
A. Yes
B. No
C. Only if the supervisor was aware of the
situation and did not intervene
appropriately
D. Only if the supervisor was unaware of the
situation but should have been aware,
i.e. was providing an inadequate level of
supervision
Answer = A
4. Can GP Supervisors undertaking remote
supervision (i.e. supervising a doctor who is not
working in the same physical location as they are)
also be held liable for the actions of the supervised
doctor?
A. Yes
B. No
Answer = A
5. Are patients seeing GP Registrars in your Practice
informed that they are being treated by a supervised
doctor or doctor undertaking further training?
A. Always
B. Mostly
C. Only if it comes up or the patient asks
D. Not generally
E. I do not know
Possible issues arising from Supervision
• Blind spots
• Failing to make the supervised doctor aware
of the circumstances in which they must or
should contact their Supervisor
• Not providing regular feedback or review, or
being inaccessible to discuss the supervised
doctor’s issues or concerns
• Failing to promptly and/or transparently deal
with errors when they occur
“Blind Spots”
• “Blind spots” are an unawareness of incompetence
which can result in help not being sought when it is
needed, potentially placing patients at risk
• This is more risky in somewhat isolated work
environments like General Practice
• It is important to remember that Supervisors can also
have blind spots
Byrnes 2012, Kamien 2004, Kruger & Dunning 1999, Wearne 2005, Wearne 2011
Criteria to Contact the
GP Supervisor
• Establishing criteria prompting supervised doctors to contact
their Supervisors is an important strategy to reduce patient risk
• Criteria can include:
– Diagnostic, e.g. recognition of a seriously ill child
– Therapeutics, e.g. particular procedural skills
– Transfer of care
– Management of sentinel or adverse events
• It is helpful to have a general template or list which is provided
and discussed at the beginning of the placement
RACGP 2008
Case Scenario 1- Competency
Dr Sam (supervised Doctor), Lucy, and Dr Watts (GP Supervisor)
•Lucy, a 16 y.o, comes in on Monday morning with a sore arm,
which she injured at netball. She is tired and headachy, with an
elevated temperature
•Dr Sam observes several lesions on Lucy’s left arm, which look
like hives. Lucy says they are itchy and sore, so Dr Sam prescribes
an antihistamine, and asks her to return if she is worse, or not
improving
•Lucy returns on Thursday morning, as she is feeling feverish and
unwell. On examination, Dr Sam notes that there is a band-like
rash in her left arm, characteristic of shingles
This case study is based on an actual event but details have been changed
to protect the privacy of those involved
Case Scenario 1- Competency
• Dr Sam checks MIMS, noting that antiviral treatment should
ideally be given within 48 hours, but can be administered up to
72 hours after the rash first appears
• Dr Sam decides that antiviral therapy is not warranted, as he
assumes that the rash has been present for more than 3 days.
He recommends over the counter analgesia and that Lucy also
apply topical lotions to the lesions
• 6 weeks later, Lucy’s mother contacts the Practice claiming that
Lucy was treated inappropriately, as she was not given antiviral
medication. Lucy has ongoing severe pain, and has apparently
developed post-herpetic neuralgia
Case Scenario 1- Competency
What should Dr Watts do?
• Check the clinical notes
• Speak with Dr Sam, to find out what happened, and ascertain
the reasons as to why this incident occurred
• Contact Lucy’s mother, to apologise, and listen to her
concerns
• Advise her insurer, and seek their guidance as to how to
manage this issue. For example, Dr Watts may:
– Arrange to meet with Lucy and her mother, to discuss
their concerns in person
– Prepare a response should a written complaint be
received
– Consider whether the therapeutic relationship should
continue, particularly if a claim for damages is made
Case Scenario 1- Competency
What if:Dr Sam says to Dr Watts that:
• The Practice is much busier than he had expected, and
sometimes he feels completely overwhelmed
• He has felt unable to approach her whenever he has any
issues or concerns regarding patients, as it is clear she dislikes
interruptions when she is consulting
• When he has spoken with her, on a number of occasions she
has dismissed his questions and told him to go and read
Murtaugh instead
Dr Watts decides she needs some advice from her insurer
Case Scenario 1- Competency
Advice from Dr Watts’ insurer may include:
•Talk to Dr Sam about the level of supervision he feels is needed
•If unable to reach agreement, discuss his supervision needs with
the medical educator from his training provider
•Randomly review 10 files of patients who have seen Dr Sam over
the previous 2 months.
– If significant concerns remain about the appropriateness of
Dr Sam’s management, Dr Watts should consider changing
their supervision requirements
•Sending in copies of the clinical notes to the insurer, as a file will
need to be opened
Case Scenario 2- Mandatory Notification
Case Scenario 2 - Mandatory Notification
Supervisor reporting Registrar
• Dr Chu receives a phone call from a local Pharmacist, querying
a script written by the Practice’s GP Registrar for
methotrexate, 20mg orally, once daily, for severe rheumatoid
arthritis
• The Pharmacist asks whether this should be once weekly,
rather than daily
• As the Registrar has already left for the day, Dr Chu checks the
very brief patient notes, which state that this new patient has
methotrexate 20mg daily, and needs a new script
• Dr Chu confirms with the Pharmacist that the correct dose is
weekly
This case study is based on an actual event but details have been changed
to protect the privacy of those involved
Case Scenario 2- Mandatory Notification
• When Dr Chu asks the registrar the following day about the
issue with dosing identified by the Pharmacist, the Registrar
maintains that the 20mg daily dose she prescribed was correct
• Although the Registrar concedes that she did not check MIMs,
she is not concerned when Dr Chu points out that oral
Methotrexate should be prescribed weekly, not daily
• The Registrar is dismissive of Dr Chu’s concerns, and says she
cannot see any problems with her management
• Dr Chu has significant concerns about the Registrar’s insight
and clinical competence, particularly as a similar, but less
serious issue has arisen in the last month
• What is Dr Chu required to do ?
Case Scenario 2- Mandatory Notification
Under Section 140 of the National Law, registered
health practitioners are required to report ‘notifiable
conduct’ to AHPRA
Notifiable conduct is defined as occurring in
circumstances where the practitioner has:a) Practised whilst intoxicated by alcohol or drugs; or
b) Engaged in sexual misconduct in connection with their
clinical practice; or
c) Placed the public at risk of substantial harm during their
practise of medicine, because of an impairment; or
d) Placed the public at risk of harm because they have
practised in a way that constitutes a significant departure
from accepted professional standards
Case Scenario 2- Mandatory Notification
• It is Dr Chu’s belief that the Registrar’s conduct placed
this particular patient at significant risk of harm
• Further, given the registrar’s lack of insight, Dr Chu
was concerned that other patients may also be at risk
• Dr Chu phoned his insurer, who agreed that there was
a reasonable basis for him to have formed the belief
that the registrar’s conduct fell within the definition
of ‘notifiable conduct,’ under s140 of the National
Law
• Accordingly, Dr Chu contacted AHPRA, and reported
the Registrar’s conduct
Case Scenario 3– Unprofessional Conduct
Breach of patient privacy and confidentiality
Case Scenario 3 –Unprofessional Conduct
Breach of patient privacy and confidentiality
• Dr Placid is an IMG, who has very little experience in
the General Practice setting. He has come to Dr
Smith’s small rural practice, to complete his first
term.
• Although he requires significant supervision, Dr
Placid is very keen to learn and wants to make a good
impression.
• After a couple of months, Dr Placid’s clinical skills
have significantly improved, and he appears to have
embraced life in the rural community.
Case Scenario 3– Unprofessional Conduct
Breach of patient privacy and confidentiality
• The annual B & S ball rolls around, and Dr Placid informs Dr
Smith that he will be attending. Dr Smith reminds him that he
needs to be careful about how he behaves, as most of the
attendees will be patients of the practice
• Although Dr Placid is feeling a little sore and sorry the day
after, he appears otherwise unaffected by the events of the
previous night
• However, after lunch, the Practice Manager comes into Dr
Smith’s office and says that Muriel is on the phone, and she
wants to complain about Dr Placid’s behaviour at the B & S
ball
Case Scenario 3– Unprofessional Conduct
Breach of patient privacy and confidentiality
• Dr Smith picks up the phone, with some trepidation.
Muriel is very angry, and says that Dr Placid disclosed
to her grandson and his friends at the B&S ball that
she had asked for a referral to a Plastic Surgeon, to
have breast implants and a lift
• Muriel claims Dr Placid was drunk at the time. She is
distressed about facing her family, and the likely
reaction she will receive from her friends at bingo.
She wants Dr Placid to be struck off and dismissed
from the practice
• What should Dr Smith do?
Case Scenario 3– Unprofessional Conduct
Breach of patient privacy and confidentiality
• Dr Smith asks Muriel to come in and have a chat with him, so
he can apologise in person
• He then calls Dr Placid into his office, and asks him to explain
what happened. Dr Placid confirms that he disclosed
confidential information about his recent consultation with
Muriel when he was feeling tipsy. He is mortified and
extremely apologetic about his behaviour
• After some discussion, they agree that Dr Placid will notify his
insurer, and seek their advice about the wording of an
appropriate letter of apology to Muriel.
• Dr Smith then has a long chat with Muriel, who reluctantly
accepts Dr Placid’s apology.
Case Scenario 3– Unprofessional Conduct
Breach of patient privacy and confidentiality
Risk Management Tips for GP Supervisors
• Clarify the supervised doctor’s roles and responsibilities
• Encourage a positive feedback environment, focussing on
improving learning and patient safety
• Be aware of the supervised doctor’s and your own “blind
spots” understandings.
• Offer timely feedback which not only
covers strengths and weaknesses, but
is corrective
• Reflect and discuss learning gaps, and
reinforce
Checklist
For a GP Registrar who is new to the practice
Checklist
Medico-legal issues
References
Australian Medical Association. Supervision and Assessment of Hospital Based
Postgraduate Medical Trainees 2012
Byrnes P. Are they safe in there? Aust Fam Physician. 2012;41:26–9
Kamien J. Educating the good GP. Aust Fam Physician. 2004;33:1027–9
Kennedy E & Heard S. Making mistakes in practice: developing a consensus statement.
Aust Fam Physician. 2001;30:295–9
Kruger J & Dunning D. Unskilled and unaware of it. J Pers Soc Psychol. 1999;77:1121–34
The RACGP. Companion Standards for General Practice Education and Training: Trainers
and Training Posts 2005 (Version 2) 2008
Wearne S. General Practice supervision at a distance – is it remotely possible? Aust Fam
Physician. 2005;34:31–3
Wearne S. In-practice and distance consultant on-call General Practitioner supervisors
for Australian General Practice? Med J Aust. 2011;195:224–8
Wearne S, Dornan T et al. General Practitioners as supervisors in postgraduate clinical
education: an integrative review. Medical Ed. 2012;46:1161–73
Questions?
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• Contact us with your concerns
– CEO Margo Field: [email protected]
• 0407 700 353
– Chair Dr. Patricia Baker: [email protected]
• 0414 869 674
– www.gpsupervisorsaustralia.org.au (awesome website!)
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Thank you and Good night!
• Thank you to our sponsor MDA National Insurance
• Thank you to the Hon. Senator Fiona Nash, Assistant
Minister for Health and her friendly staff.
• Thank you for participating