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Training registrars: embarking on a new challenge

1 December 2005

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Lorna MG McMillan
Practice Manager/Associate Trainer
Abington Medical Centre
Abington Health Complex

Outside work I am a fanatical golfer; other hobbies include eating fine food and drinking fine French wines (or anyone else’s), making my own greeting cards and spending time with my lovely grandchildren – as someone said, “If I knew how much fun grandchildren were, I would have had them first!”

I have been involved in training in one guise or another for years, also participating in training practice assessment visits. When the question was asked, “Would I like to be a GP Trainer?”, I jumped at the opportunity – this was a new venture by the Leicestershire, Northamptonshire and Rutland Deanery, a very exciting prospect and an opportunity not only me but also for the practice.

Becoming a trainer
The preparation is not vastly different from that of a GP preparing to become a trainer, except the MRCGP requirement. All new trainers will have to have the Postgraduate Certificate of Medical Education, and the LNR Deanery arranged with De Montfort University for the new trainers course to be accredited. This is a five-day residential course split – two days and then three days. It also involves two essays, a personal learning plan, and two interviews about teaching/learning skills.

My experience as a trainer
I joined the local trainers group, where I was made to feel very welcome, attended two residential trainer courses, and was coasting along nicely. In my own mind I had planned a leisurely lead-up to becoming a trainer. With one phone call my calm world collapsed: the deanery were stuck – would I accelerate my training situation? They had a registrar who had failed his simulated patient part of summative assessment; he needed a further six months. I would become an associate trainer.

The practice partners were very supportive and agreed, but a huge problem loomed: we would have in a short space of time 10 doctors and eight rooms. Still, as all practice managers are very resourceful, I came up with solutions such as hot chairing, building a skyscraper, splitting rooms in two and getting quotes for Portakabins.

I accepted the challenge and by that afternoon had the registrar in my room for the initial interview. Neither of us had a clue, but I think we reached a plateau whereby it was OK. I didn’t know what I was doing, he didn’t know what he was doing, so we would help each other.

That evening I sat in a very comfy chair with a very large glass of wine, planning the registrar’s four-week timetable, something I was used to doing – when it dawned on me that his weekly tutorials were my responsibility and not just towards the end of training. I would even have to organise clinical tutorials with the partners.

By Friday lunchtime panic had set in – headless poultry came to mind – but I had been told of a marvellous website, a surgery that had a complete site devoted to training, so downloading documents became a must. Wonderful folders produced with lots of different forms, summative assessment, video regulations, consent forms and structured trainers reports, to name but a few. Would I ever need them all? Only time would tell.

  • What was going to be my responsibility?
  • How was I going to address the registrar’s clinical needs and ensure they were met?
  • The video consent form would have to be amended.
  • I would have to set aside a whole morning a week for tutorials.
  • How was I going to organise my workload?

A whole jumble of thoughts raced through my mind that weekend, not least because I had only one and half weeks to prepare, with a six-day trip to France included. What a way to plan training, French food and, more importantly, French wine. I thoroughly recommend it.

R-Day had arrived, plans ready, room ready; I decided to turn up at the surgery early (my husband just loved that, as he was on chauffeur duty due to my left arm and hand being in plaster). We turned into the car park at 7.20am and there was a strange car: “Darn those neighbours, I wish they would not use our car park.” I got out of the car to be met by MY registrar. He didn’t want to be late on his first day. OK, I could understand that, but one hour and 10 minutes early was a bit excessive.
I automatically went into nurture mode: “Would you like coffee?” I asked, and, when receiving an affirmative answer, I immediately showed him the kitchen!

We spent the morning getting to know one another, filling in the myriad of forms, and fitting in a visit from the Director of Postgraduate Education LNR to discuss the next six months and also answer any questions I had. Of course I had questions – I just didn’t know what they were!
R-Day + 1 – the Registrar’s day on call – well, not that week, but it would be in future weeks, sharing it with one of the partners. Then disaster: one of the partners phoned in sick, with one on holiday and only a salaried GP to do the open-access surgery. Still, ever flexible, I threw my registrar in. Minor problems with the setup of the computer – we couldn’t put in diagnosis and then we couldn’t print prescriptions – but we got there in the end and patients were satisfied. I managed to get time to myself that afternoon to do practice management work as he was doing surgery with one of the partners; we met up later in the afternoon to discuss how things had gone. Then, thankfully, it was home, more large glasses of wine – at this rate I could become an alcoholic. Then the actual date dawned on me, a 3,000-word essay had to be submitted by the 28th, so forgot the wine, brought on the word processor and some brain cells. I also needed to prepare for my first tutorial the following week. I had received my registrar’s skills assessment analysis and knew we had to do an educational learning plan. Someone mentioned a “kiddie ring”; is that some sort of life-preserver, I wondered?

Blessed relief, it was the weekend and I could recharge my batteries (more wine!).
Monday came around all too soon, but then I remembered Mondays are my registrar’s day off, so I could be a practice manager again. On Tuesday, there he was in the car park again, waiting for me. We sat and chatted for about 45 minutes, and this seemed to have set the pattern for the remainder of his time in practice. Still, we established a relationship, which is important.
The next hurdle was my interview with someone from the deanery who started off the whole thing of managers as trainers. We went through the trainer’s criteria – another hurdle completed.
Hurdles did seem to be coming at short intervals. The registrar approached me: “I need to do some out-of-hours”. Oh, did I have to organise that as well? So, armed with the out-of-hours rota, it seemed Saturday morning would be ideal; thank goodness one of our partners was on and agreed to supervise. (Hindsight – no I do not have to organise this, it is down to the registrar to organise.)

One of the things I needed to get used to was debrief, not for clinical problems, because these I pass over to a clinician, but just the logistics of the surgery, what he felt went well and what he felt went wrong.
Friday over and it seemed as though I had had a registrar for far longer than a week and two days.
I heard I passed the Certificate Of Medical Education and received the date for my first practice inspection as potential trainer. The inspection went well, although I had to prepare a video recording of one of my tutorials – I found this very daunting, but a good exercise in understanding how difficult it is for registrars when they are recording their consultations. I now await my formal interview by the worthies of the LNR Deanery.

Time sped by and it was time for my first registrar to leave. He passed his simulated patient exam and got a salaried GP job. So, a success for everyone in the practice – it was a team effort.
The registrar traditionally forms a bond with his trainer. Not having clinical skills, I felt, was not a disadvantage, and we did manage to establish a relationship. In fact, my first registrar was exceptionally pleased with his training and felt he and any other registrars coming into our practice were exceptionally lucky.

I see my role as:

  • Being responsible for the registrar’s pastoral care.
  • Through discussion with the registrar and the clinicians, identifying any shortfalls in clinical skills.
  • Debriefing by a clinician, looking at clinical and nonclinical aspects of the surgery.

Each week, without fail, a clinician will sit in on a surgery – a different clinician each week – and registrars will be doing a joint surgery with a clinician each week so they get a feel for different consulting styles and also for safety netting.

It is not the easiest of jobs, being a practice manager and a trainer. You need the backing of all the clinicians and administrative staff. I am very fortunate to have an exceptionally skilled and helpful workforce: four partners have been involved in training, two of whom have been course organisers, and I certainly couldn’t do both jobs if it wasn’t for the help and understanding I receive from everyone at the surgery.

Of course this is a very contentious issue at the moment, but I sincerely hope that this innovative scheme does not get choked off before it has had time to blossom. There are many managers who would make good trainers, but they cannot do it alone. The help, backing and expertise of their partners and staff is essential.
I see the future of training as being a “whole practice” project, and it is a future that I find very exciting.