Sink or swim ?

What problems do you think as NQGPs you feel unprepared for? In 3’s

How well does GP training prepare doctors for the transition into independent professional practice? A qualitative study exploring the issues faced by newly qualified General Practitioners: by Martyn Hewett.

Method recent graduates of GP training individual or small group guided interviews themes identified focus group of recently qualified GPs to prioritise themes second focus group discuss and refine an action plan

First catch your tiger …or NQGP Nobody owns them, nobody has responsibility for them; PCTs, deaneries, RCGP, local postgraduate medical centres etc. all “blind” to them – no registers, no records. May have left the area, some the profession, some the country. A lost tribe…? those who might be in greatest need of a mentor are likely to be those least able to access one – modern day educational equivalent to Tudor Hart’s inverse care law? (Hart 1975).

Themes from interviews and focus groups Pressures on NQGPs Support and back-up needed Working as a locum Working in non-training practices Coping with loss How should GP training change? What educational provision should there be for NQGPs?

Pressures on NQGPs High levels of anxiety Clinical uncertainty, compounded by not having time to look things up “The first kind of month I thought ‘I am just about ready for this’ and actually over the past five months have proven that I wasn’t quite ready for it at that time…I just feel so much more comfortable and capable now, in terms of managing the surgery without feeling anxious, panicked, and stressed, which was a fairly consistent feeling for the first three months or so.”

Pressures on NQGPs High levels of anxiety” Baron et al (1998) – similar methodology. Found that new principals identified: their perceived lack of clinical knowledge, the problems of coping with demanding patients, the stress caused by “on-call” work, and the difficulty of coping with the emotional impact of their work. Baron, R, et al. (1998) The training needs of young principals. Education for General Practice, 9, 403-409 Main, PGN (1998) Extend the GP registrar year, Training update, March, 2.

Pressures on NQGPs (2) Time pressure Workload Especially if moving to a new practice or geographical area only just over 50% of qualifying GPs stay in the same deanery (Johnson et al 1998) Workload Increase in number of patients seen per session x number of clinical sessions worked per week Johnson, N, et al. (1998) The career outcomes for doctors completing general practice vocational training 1990-95, British Journal of General Practice, 48, 1755-1758

Need for support and back-up Feeling of having to “know it all”. Can they ask for advice? “…it seems bizarre that you go overnight from being this slightly sort of supported special thing Registrar and it’s OK to ask questions, but now it is not. In a new place where nobody knows you and you are supposed to have all the answers…you are supposed to have everything at your fingertips and know it all and be independent”

Need for support and back-up Expressed need for back-up “You haven’t got somebody covering you when you are on-call. Psychologically I think it is a bit of a step…you have to be a bit more resourceful and a bit more independent really…I know there comes a stage where you have to be accountable and ‘you’re it’ sort of thing…I haven’t actually done this yet, but I can imagine being an Out-of-hours doctor is actually another step, another jump as well - being on your own in the car somewhere.”

Working as a locum Particular problems Setting up as a locum Demanding patients Tend to see a lot of self-limiting illness Professional isolation (e.g. compared with a salaried post) “You would see patients, you would refer them or whatever, and one typically would go home and wonder what happened to them…(it) was always nice to kind of ‘close the case’, the episode, you know, reflect back. Was I right? Was I wrong? Did this work?...it is not always easy if you don’t know what happened.” Setting up as a locum Computer skills (EMIS, Vision, System1 etc)

Working in non-training practices Staff (and doctors) in training practices tend to understand the capabilities of NQGPs, whereas those in non-training practices may not

Coping with loss of supportive networks Not reported in previous studies Forming – Storming – Norming – Performing – Adjourning “the break-up of the group after successful completion of the task” …can be stressful, involving the termination of roles and the loss of supportive peer relationships. However, rightly handled, the process can lead to personal growth in individuals, who become energised, enthused and more resilient for future challenges and tasks How do we handle this process at the end of GP training? Tuckman, BW (1965) Developmental sequence in small groups. Psychological Bulletin, 63, 384-399

How has GP training changed? Clearer advice on how to navigate the transition, manage workload etc. Joining in with the CPD programme More independent time towards end of GP training

Locus of Control

Locus of Control As the environment around you changes you can attribute success & failure to things you have control over Or to forces outside your influence Which orientation you choose can have a bearing on your long-term success What is your perception?

Locus of Control EXTERNAL Outcomes outside your control Independent of your decisions or hard work ‘Fate’ INTERNAL Outcomes within your control Determined by your hard work & decisions ‘Own destiny’

What are the advantages/disadvantages?

Locus of Control Men & managers are more likely to have an internal locus of control As we grow older we generally move towards a more internal locus of control This is usually because we can have more influence on things going on in our lives And we learn what happens to us is often a result of what we do As people grow older they tend towards a more internal locus of control. This comes from the increased ability to influence things going on in their lives and the realization that much of what happens to them is a result of what they do.

Internal Locus Style Engage in activities to improve their situation Work hard to develop knowledge, skills and abilities Inquisitive to find out why things turned out that way Use that information to create positive outcomes moving forward

Develop your Internal Locus Recognise you have a choice, even if you choose to do nothing Set goals & grow your self confidence Practice decision making & problem solving Re-programme your inner voice But don’t bruise others…

Career Resilience Internal Locus is one of a range of useful attributes, Can you think of any others? Nt

Career Resilience Internal Locus is one of a range of useful attributes, others include Being Flexible & creative Having a Sense of purpose Optimism Courage & determination Minimising focus on blame or guilt Problem solving skills Capacity for emotional expression (positive & negative) Nt

It’s the way you look at it…

What educational provision is there for NQGPs?

CPD: How will you know what education you will need? Some suggestion that certain health professionals find it more stressful when put in a situation that requires them to be a “self-directed learner”

Peer support Exists in most (but not all) areas

Mentoring…. Mentoring programme Being newly qualified: a “time of anxiety and uncertainty”, many professionals experience a “reality shock” (a time of disorientation) support is helpful to enable them to navigate this period of “transitional learning” (all from Morton-Cooper & Palmer, 2000 p89) Morton-Cooper, A & Palmer, A (2000) Mentorship, Preceptorship and Clinical Supervision – a guide to professional roles in clinical practice. 2nd edition. Blackwell Science.

What is a Mentor?

Definitions of mentoring? Support – listening, providing structure, expressing positive expectations, sharing ourselves, making it special. Challenge – setting tasks, engaging in discussion, heating up dichotomies, constructing hypotheses, setting high standards. Vision – modelling, keeping tradition, offering a map, suggesting new language, providing a mirror. Daloz, L (1986) Effective teaching and mentoring. Jossey-Bass, San Francisco

Severn Mentorship Programme “An organisation which offers structured mentorship is an organisation with more fulfilled, committed, resourceful and motivated employees, who will stay within that organisation” Cunningham I (2001)Mentoring: its role in changing the organisation culture. Centre for Self-Managed Learning, Middlesex University, Middlesex. Partnership between Severn Deanery School of Primary Care Severn Faculty RCGP PCTs With additional funding from the South West GP Trust Each NQGP can opt in to have access to a mentor for 2 years post-CCT Started with Swindon, Gloucestershire & Bath in 09, rolled out to Bristol & Somerset in year 2

So what happens? Administered by Severn Faculty RCGP Matching of NQGPs to mentors Confidential learning relationship between two doctors Time and space to reflect on career; but may be appropriate to bring in life events Initially face-to-face contact, but later could be telephone or email Experience elsewhere (eg Thames Valley Faculty RCGP) suggested initial contact at 6-8 weekly intervals

What do people use it for…? Appraisal & revalidation Keeping up-to-date and recording learning Jobs – locuming vs regular work Choosing a salaried post Maternity leave Career plans Issues in salaried posts Work relationships Clinical situations Stress Workload Negotiating Dealing with uncertainty Local educational facilities available

Questions?