Simulation

What motivates general practitioners to teach Jennifer Thomson, Emily Haesler, Katrina Anderson and Amanda Barnard, Australian National University Medical School, Canberra, Australia

The desire to update clinical knowledge was the most frequently mentioned motivation for teaching

SUMMARY Introduction and aim: The Australian general practitioner (GP) teaching workforce will need to expand in order to provide for the increasing number of medical students and doctors-in-training. Understanding factors that motivate GPs to become involved in teaching in their clinical practice environments is important for developing recruitment and retention strategies. Method: Thirty-one semi-structured interviews were conducted with a cross section of GP teachers and were subjected to thematic analysis. Themes were identified and further classified

as motivations and prerequisites for teaching. Results: The desire to update clinical knowledge was the most frequently mentioned motivation for teaching, and was described as a strategy for GP teachers to preserve clinical competence through the opportunity to learn new aspects of medicine from junior colleagues. Other motivations included personal fulfillment and enjoyment of teaching, the opportunity to pass on general practice skills and knowledge, promoting general practice as a career, and fulfilling a sense of responsibility to the profession and community. Peers, students and patients also

influenced the decision to teach. Most GPs identified that time, workload, availability of space and adequate financial remuneration were prerequisites for teaching. Practice owners also often determined the GP teachers’ capacity to teach. Discussion: To increase the recruitment and retention of GP teachers, it is recommended that teaching organisations give more recognition to teaching as a clinical professional development activity, place more emphasis on GPs’ personal enjoyment, professional responsibility and pride in teaching, and increase engagement with practice owners.

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INTRODUCTION

An understanding of factors that motivate GPs to become involved in teaching is important

T

he worldwide workforce shortage of family doctors has resulted in an increased focus on training capacity.1 In Australia, there is additional pressure on clinical general practice teaching capacity,2 with recent increases in the number of medical students and doctors-intraining, and an ageing general practice workforce, with 42 per cent of GPs currently aged over 55 years.3 As in other countries, Australian general practices are largely privately run businesses, with no requirement to take on a teaching role.4,5 An understanding of factors that motivate general practitioners (GPs) to become involved in teaching is important to developing strategies for recruitment and retention of a GP teaching workforce that will meet future demand. Barriers to teaching include lost time and money, and the associated infrastructure and administration costs.3,6–8 However, the motivations for GPs to teach have not recently been investigated in detail.9 Current literature suggests that altruistic, intrinsic factors may have the strongest influence on a clinician’s motivation to teach.10–13

We used a qualitative research methodology, and undertook semi-structured interviews with GP teachers. Ethics approval was obtained from the Australian National University Human Research Ethics Committee.

Territory and south-east New South Wales region to participate. Thirty-four GPs registered an interest, meeting the predetermined minimum number of 30 participants. We employed a purposive sampling strategy based on maximum variation to ensure participants would reflect the variation in demographic characteristics of GP teachers in the region. We selected all GPs who had registered an interest; however, circumstances prevented us interviewing two respondents and a third withdrew interest, leaving 31 GPs meeting the sample criteria. We undertook face to face interviews using a set of open-ended prompt questions and audio-recorded and transcribed the interviews.

We invited, by letter, the total cohort of 225 registered GP teachers in the Australian Capital

We conducted a qualitative analysis of the transcripts using thematic analysis techniques

This research explores the factors that motivate GPs to teach medical students, junior doctors and registrars in their clinical practices.

METHODS

aided by the use of the software package NVivo 9. Two of the co-investigators identified and categorised primary emerging themes in a consensus fashion as the interviews were being conducted. The primary investigators discussed emerging data and provided additional focus for interviews as they progressed, allowing for the exploration of the themes and feedback from participants throughout the data-collection phase until thematic saturation was reached.

RESULTS The final sample of participants (n = 31) represented GP teachers working within the region with a variety of characteristics (Table 1). The main themes identified in the interviews were categorised

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Teaching was seen as a way to preserve competence and up-to-date knowledge

as motivating factors and prerequisites for teaching, as presented in Table 2.

Table 1. Demographic characteristics of participants; GP Teachers (n = 31) Interviewee characteristics

Motivating factors Factors that motivated GPs to teach are described below, with supporting quotes from GP teachers presented in Box 1. Professional development as clinicians The most common motivation for teaching was the GP teacher’s desire to update their clinical knowledge through the process of teaching. Teaching was seen as a way to preserve competence and up-to-date knowledge through contact with junior peers who are learning new aspects of medicine. Personal fulfilment and enjoyment The second most common motivating factor was personal fulfilment and enjoyment. Social interaction, relationships with learners and a sense of making a difference contributed to personal enjoyment. General practice knowledge and skills Many interviewees stated that passing on their general practice clinical knowledge and skills to future doctors was important. They also mentioned a desire to preserve the discipline of general practice. Promotion of general practice Another motivation for teaching, particularly for rural GPs, was promoting general practice as a career option. A responsibility to train GPs for the future to benefit the profession, community and their patients was a motivation for many. Influence of others: students, peers and patients The GP teachers indicated that positive informal feedback received from students, patients, peers and mentors influenced them to continue teaching. GPs also said that the example of GP

Gender

65% male 35% female

Practice location

74% urban 26% rural

Practice size

23% small (1–2 FTE* GPs) 58% medium (3–5 FTE GPs) 19% large (> 5 FTE GPs)

Practice ownership

74% practice owners 26% practice employees

Teaching status**

94% current teachers 6% non-current teachers

Experience as a GP

93.5% >9 years 6.5% 5–9 years

Teaching experience

42% < 5 years 16% 5–9 years 42% > 10 years

*FTE: full-time equivalent. **Teaching status: i.e. learners currently in the practice.

Table 2. Most frequent interview themes Themes

Number of GPs identifying theme

Motivating factors for teaching Clinical professional development: revision or learning 23 Enjoyment of teaching

21

Passing on general practice knowledge

20

Influence of students

18

Promoting general practice as worthwhile career

17

Sense of responsibility to the profession and community

15

Influence of patients

14

Demonstrating quality patient care

14

Influence of peers

12

Feedback from university

12

Feedback from students

10

Prerequisites for teaching Time

30

Adequate payment

22

Support in teaching role

16

Space

12

Employment status/life stage

12

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Box 1. Motivations to teach – GP quotes Professional development as clinicians ‘They teach me. Particularly the theoretical stuff, which is good…obviously they haven’t done 150 000 consultations or whatever that I’ve done, but their theoretical knowledge is excellent and between the two of us we teach each other.’ (GP25) ‘They’ve had new knowledge, very recently, and sometimes there are ideas that I have not come across…you get exposed to things that you may not realise you don’t know about.’ (GP14)

Almost all GPs identified time constraints as the most significant barrier to teaching

Personal fulfilment and enjoyment ‘I enjoy teaching. I guess I feel passionate about teaching and I’ve enjoyed doing it for a number of years now.’ (GP12) ‘I enjoy seeing people learn and enjoy even more seeing people learn to learn.’ (GP13) General practice knowledge and skills ‘It’s quite a variety of things we do, so I think that it is good to show them what we do in general practice.’ (GP2) ‘I’m a big believer in general practice…I’m really keen for people to understand the advantage of continuity of care, and I think that continuity of care is hugely beneficial for both patient and doctor.’ (GP17) Promotion of general practice ‘Because we had a shortage of rural doctors for a long time and it was very hard to get anybody to come and be a GP in our town that when the [teaching organisation] started we thought this would be an opportunity to eventually increase the supply of doctors that would come to our area.’ (GP28) ‘The main motivation for teaching medical students [is] that I think as GPs we need to improve the status of general practice in the minds of students as an option for their career.’ (GP21) Responsibility to profession and community ‘I just feel I owe the profession a sense of duty. If we consider [the] oaths we are supposed to have taken at the end of our career then that’s part of it.’ (GP10) ‘I do have an innate sense of responsibility to society too.’ (GP14) Demonstrating quality clinical care ‘I do have a lot of complicated geriatric patients with lots of co-morbidities…they do come in with lots of issues. That’s good from a teaching point of view.’ (GP10) ‘One of the things I try to get through to the students is the personal nature of the relationship between the GP and his patients or her patients, how long we’ve been interacting with families.’ (GP26) Influence of others: students, peers and patients ‘Obviously if you get somebody who is really keen to learn and ask lots of questions and is motivated then it makes you a bit more motivated.’ (GP20) ‘I think the patients enjoy it actually, from the feedback I’ve been getting.’ (GP1) ‘My good teachers were an inspiration to me…I like to copy them or do what they do because they impressed me.’ (GP6) Feedback on teaching ‘I have received a little feedback about the teaching, more from the individual students that I had on a one-to-one basis. I can’t say I’ve had any great feedback from the [teaching organisation]. I did from the students.’ (GP10) ‘I always find that it’s difficult to know myself whether I’m providing what is required, so I’m always trying to give myself feedback as to what happened during every event that occurs.’ (GP19)

peers often influenced them to commence teaching. Formal feedback on teaching Interviewees wanted formal feedback on their teaching performance from both learners and teaching organisations.

Teaching organisations did not generally provide such feedback; however, students sometimes did so, informally. Prerequisites for teaching Interviewees identified a number of factors that were important

prerequisites for teaching. Quotes from GP teachers are contained in Box 2. Time Almost all GPs identified time constraints, largely resulting from high clinical workloads and

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Altruism and enjoyment are common motivations for clinical teaching in the private sector

Box 2. Prerequisites for teaching – GP comments Time ‘Always pushed for time.’ (GP1) ‘Time is the most important factor in teaching.’ (GP11) Remuneration ‘So if I was given a choice and I needed the money and it was a choice between having the money and not teaching, teaching and not earning money, there is a breaking point again where I would say, well I need money. So it does affect me and I don’t think that teaching should be undervalued by being paid less.’ (GP27) ‘I enjoy the academic part, definitely not for the financial reward, which is very minimal compared with what you earn in general practice and private practice.’ (GP6) Space ‘Again, that just depends on space availability and whether…whether we’d have any room.’ (GP2) ‘We’re limited for space here as well.’ (GP6) GP status and life stage ‘That [teaching] would have to be decided by the [practice owner], so… yeah, but I don’t think he’s taking any at the moment…’ (GP2) ‘I don’t run the clinic, it also depends on the [practice owner].’ (GP20) ‘I think we are more likely to get people at the end [of their careers], because we have done our hard yards, and now we’re willing to put something back into the system…’ (GP1) ‘Maybe as I get close to retirement I might take on different teaching roles if they are available.’ (GP26) Professional development as teachers ‘I could always do with more training I think. I haven’t received really any formal training.’ (GP12) ‘Getting supported to do a Grad. Cert. was really good.’ (GP31)

a perceived increase in work associated with teaching roles, as the most significant barrier to teaching. Some participants mentioned new teaching methods that they had applied in their practices to compensate for these time pressures. Adequate remuneration and space Most GPs indicated that an adequate level of remuneration, as well as additional consulting space, was needed to enable teaching to occur. GP employment status and life stage The employment status (e.g. contractor, employee, practice

owner) of the GP within the practice often determined whether a GP was able to teach. In some practices, practice owners either did not permit contractors and employees to teach, or limited their teaching effort. The life stage of GPs had some influence on their willingness to teach. Participants who had increased family responsibilities viewed a higher teaching commitment as impractical. Older GPs saw an opportunity to increase their teaching as they neared retirement and reduced their clinical work. Support in teaching role: professional development as teachers

A significant number of GPs requested further peer support and teacher training, particularly around assessment and curriculum requirements. There was little interest in academic status, although GPs appreciated some form of recognition.

DISCUSSION This research has highlighted a range of motivating factors for GP teachers. Universities, GP training organisations and professional bodies will need to consider some of the recommendations that emerge from these research findings. Nearly all interviewees identified that teaching provided an opportunity to learn from junior colleagues and stay up to date clinically. This was a strong motivation for teaching. This finding has not been clearly identified in previous research, and requires some further attention and exploration. Registration and credentialing bodies and academic organisations could further research the effectiveness of teaching in maintaining clinical competence, and give appropriate credit to GP teachers in continuing professional development programmes. Teaching organisations must also recognise that altruism and enjoyment are common motivations for clinical teaching in the private sector.14 Marketing this aspect of teaching to new teachers is important. Further exploration of specific aspects of teaching that are enjoyable, and finding ways that these may be enhanced, could be important in maintaining teachers. An important finding is that a number of the GP teachers who were employees indicated that they were limited in their capacity to teach because their practice owners were not committed to teaching. This may present a challenge in

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future retention and recruitment of both teaching practices and GP teachers, as an increasing number of GPs move into an employee or contractor status, and practice owners are not necessarily GPs. Teaching organisations must engage with general practice owners as well as individual clinicians. This may include further system-wide development of streamlined funding packages by universities and GP training organisations,15 as well as marketing the business advantages of teaching.

capacity.20 Such infrastructure support, as well as adequate remuneration of teachers, will need to be maintained as the numbers of learners in general practices increase.21 Limitations of the research The research was limited in that the participants were predominantly current teachers and were self-selected. The research was conducted in one region of Australia and will need further testing in other contexts to ensure its broader applicability.

CONCLUSION Support for clinical teachers outside of the hospital and university environments is limited, and needs some attention. Peer support and influence could be further developed with, for example, a ‘buddy’ system for teachers, with mutual peer support, as is used in other sectors.16 Teaching organisations must also develop formal mechanisms for useful and timely feedback to clinical teachers. Engaging retiring GPs in a teaching role will also assist in maintaining an experienced pool of GP teachers.17 This may involve developing different expectations around the clinical practice and professional development requirements for this group. These results also provide some guidance to teaching organisations on important teaching prerequisites for clinical teaching in general practice businesses. GP teachers are developing their own solutions to the time pressures of teaching in busy practices, such as ‘vertical integration’,17 ‘parallel consulting’,18 and ‘teaching on the run’,19 which need to be further identified, developed and shared with other GP teachers. In Australia, recent government infrastructure funding grants have increased teaching

This research has given some insight into the motivational factors and aspirations of GP teachers. It provides a strong basis for implementing new strategies of engagement with this important sector of the medical education team. A number of further areas for study have been suggested by this research, including: the recognition of GP teaching as a clinical professional development activity; engagement with practice owners, patients and the community in the GP teaching process; enjoyment of teaching and how it might be enhanced; support for timeefficient teaching models; and exploration of teaching motivation with GPs who have no history of teaching. REFERENCES 1. Roberts RG, Hunt VR, Kulie TI, Schmidt W, Schirmer JM, Villanueva T, Wilson CR. Family medicine training—the international experience. Med J Aust 2011;194:84. 2. Thistlethwaite JE, Rudd MR, Hudson JN. General practice: a leading provider of medical student education in the 21st century? Med J Aust 2007;187:124–128. 3. Britt H, Miller GC, Charles J et al. A decade of Australian general practice activity 2001–02 to 2010–11. General practice series no. 30. Sydney: Sydney University Press, 2011.

4. Zwar N. Family medicine in the USA – an Australian perspective. Aust Fam Physician 2010;39:360–361. 5. Pedersen KM, Andersen JS, Søndergaard J. General practice and primary health care in Denmark. J Am Board Fam Med. 2012;25:S34–S38. 6. Christensen S. Supporting clinical teachers: A review of the literature. Aust Fam Physician 2008;37:247–249.

Teaching organisations must engage with general practice owners as well as individual clinicians

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This research has given some insight into the motivational factors and aspirations of GP teachers

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19. Tran P, Laurence J, Weston K, McLennan P. The effect of parallel consulting on the quality of consultations in regional general practice. Educ Prim Care 2012;23:153–157. 20. Catchpole M, Albert E, Lake F, Brown T. Teaching on the run – general practice training between

consultations. Aust Fam Physician 2005;34:47–50. 21. Laurence C, Black L, Cheah C, Karnon J. Is different better? Models of teaching and their influence on the net financial outcome for general practice teaching posts. BMC Med Ed 2011;11:45.

Corresponding author’s contact details: Dr Jennifer Thomson, Academic Unit of General Practice and Community Health, Australian National University Medical School, PO Box 11, Woden Australian Capital Territory, Australia. E-mail: [email protected]

Funding: Coast City Country GP Training Ltd; ANU Medical School. Conflict of interest: No competing interests to declare. Ethical approval: Australian National University Human Research Ethics Committee Protocol number 2010/090. doi: 10.1111/tct.12076

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What motivates general practitioners to teach.

The Australian general practitioner (GP) teaching workforce will need to expand in order to provide for the increasing number of medical students and ...
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