Year Four Clinical Skills

Teaching in General Practice - Year 4

The year 4 student group is divided into 4. In each of the 4 terms of 9 weeks, a quarter of the students rotate through General Practice. The other 3 rotations include Psychological Medicine, Women’s Health (obstetrics and gynaecology) and Children’s Health (Paediatrics)

In the general practice rotation students should spend up to 36 sessions at a general practice (Tuesday’s, Thursday’s & Friday’s). At Notting Hill the students participate in lectures, tutorials, practicals and simulation sessions (Monday’s & Wednesday’s) where they practice consulting skills & discuss clinical cases.

Dates for year 4 GP placement

AM & PM sessions (3+ hours) Tuesday’s, Thursday’s or Friday’s

• Rotation 1 –from 7th February to 5th April
• Rotation 2 - from 10th April to 8th June
• Rotation 3 –from 3rd July to 31st August
• Rotation 4 - from 4th September to 2nd November

Year 4 GP placement expectations

• Students can observe (but should be involved by writing up patient notes)
• Students should be able to take histories
• Students should be able to do examinations
• Students should be able to do some procedures under supervision
• Students should discuss appropriate investigations & management
• Students need to do a diabetic assessment
• Students can do any other health assessment – e.g. mental health, 45 year old, over 75, multidisciplinary care plan
• Students will write up a patient with a chronic illness whom they have seen a couple of times at your clinic (assessed by Monash academic staff)
• Students will write a referral letter to a specialist for the chronic illness patient (assessed by Monash academic staff)

How the GP can help the Year 4 student during the placement

• Welcoming, warm, nurturing environment to promote general practice. Our attitude & behaviour can significantly influence a student’s desire to become a GP in the future. (Think about your student days!)
• Find a willing patient for the chronic illness study, the diabetic assessment and any other health assessments
• Ensure opportunities for students to take histories, do examinations, do supervised procedures, discuss investigations & management
• Provide feedback to encourage and improve the communication, examination and management skills of the student
• Inform patients – notice/sign at reception desk & consent form
• Discuss with reception staff, nurse & other doctors – patients “prepared”, other activities that student may benefit from? – ECG, injections, plasters, venepuncture, syringing etc
• Complete the Student Assessment form as accurately as possible in week 9. (Note that immediately at the completion of each student visit the attendance form should be signed – required for PIP payment)

Suggested program for year 4 medical student GP placements

Session 1 - Welcome, introduction and orientation to practice. Student spends time with practice manager, reception staff and nurse to learn about patient billing – item numbers, bulk bill, standard consultation, TAC, WC etc. How system works re different payment systems including gap (patient bringing in cheque), when check doesn’t come in, follow-up of rejected claims (reasons for rejecting), doctor as contractor versus owner, corporate practice, other income streams, costs of running a practice, follow-up of results, booking appointments, CME, practice accreditation, risk management, tracking of test results or adverse events, PIP, SIP, OHS requirements, procedures manual, use of guidelines in management, drug rep visits, security for doctors and staff including infectious waste disposal, council requirements. ALL of these activities DO NOT have to be covered but those that the practice deems important & or that the student would like to learn about should be covered.

That is, when the student first arrives, a good idea is to sit the student down and discuss with them what they hope to achieve during the placement APART from the set activities. Hopefully this discussion will highlight things from the list above that are worth covering. If not then risk management issues (tracking results, guidelines, security) should take priority. Another activity could be acting as receptionist to understand the patient- receptionist dynamics – will inform student about what the doctor often doesn’t know!

Please note that some students DO NOT see themselves as GPs and if this is known up front a program that engages them can be more easily adapted. Obviously their professional behaviour should also mean that they will see the importance of being fully involved during the GP rotation (just as they should be for women’s health, children’s health and the psychiatric rotations). Thus it is a good idea to find out at the beginning of the visits, what the student thinks their goals are from attending the practice.
Preferably at the end of session 1 the student is introduced to a patient with a chronic illness. The student takes their complete history and does an appropriate examination. This patient should be prepared to help with the education of the medical student and facilitates the student’s ability to complete one or their assessed activities – the Chronic Illness Study.

Session 2 - student sits in with the doctor and writes all the notes from each consultation – freeing up the doctor and educating the student on what needs to be in the notes for medico-legal reasons + educating them about computer software packages as they learn to bring up different screens for writing scripts, writing sick certificates, filling in allergies, writing referrals, ordering pathology and radiology investigations etc. This is important learning!

Session 3 – student interviews patient whilst the doctor writes the notes. The doctor can interrupt if needed. Student also does the examination and the doctor types in what the student has found (can check student findings if need). You have the opportunity to observe the skill of the student in these domains.

Session 4 – if you have a spare room and the student is capable (from your assessment in session 2 & 3), the student is booked to see their own patients, whilst you (the doctor) sees other patient(s). After you have seen your patient(s), you (the doctor) check on what the student has found and help the student with management of this patient as required. (e.g. book 2 patients for the 9.00AM time slot – one for student (check at time of booking that the patient is happy for this to happen – often elderly chatty patients are keen to help with the education of future young doctors). By this process the doctor is not slowed down significantly and the student obtains hands on experience that they value and is best for learning. Thus the doctor sees the same number of patients as they would see without a student and the doctor (GP supervisor) has a very good idea of the student’s competency.

Note that if the student is very slow (or likely to be), allow the student more time with each patient (whilst the doctor sees a couple of patients in another room). The student should become more competent and able in subsequent sessions.

Other sessions – Sessions where the student sees their own patient’s should predominate. However, some sessions could be devoted to enabling the student to spend time again with the chronic illness patient, to do health assessment activities such as the diabetes, over 75, mental health, 45 year old etc (as appropriate and available for the student to complete). These could be done with the assistance of the GP or nurse.

The student could spend time with practice nurse, practice allied health staff, local pharmacy, go on home or nursing home visits to obtain another view of general practice.
Also remember that if there are other doctors at the practice who have interesting cases or there are procedures that the student could do (e.g. suturing) then it would be good if the student could become involved.

About 15 minutes should be set aside about half way during the student placement to provide the student with feedback to facilitate their learning. During this time please comment on their PROFESSIONALISM (respect for you, patients & practice staff, punctuality, interest and engagement) and their SKILLS (taking histories, writing notes, doing examinations, procedural skills, clinical reasoning and ability to formulate management plans for patients).

Always start by asking them to rate these attribute. Then compliment them on areas where they are good before finally focusing on areas for improvement (can set them goals for next sessions).

Do not be afraid to tell them the truth. Feedback is essential to enable development and learning.

End of each day – sign the attendance sheet to ensure you receive PIP payments

Last session with student – set aside about 30 minutes to complete your assessment of the student’s attributes/abilities
Do not be afraid to ask them to leave to get a coffee/tea whilst you complete this form so you don’t feel pressured.
Do not be afraid to provide negative comments (along with positives). GPs are ‘nice’ people and like to be ‘nice’ to students but if poor professionalism has been demonstrated, this may correlate with views of academic staff or others enabling something to be done. However, if you give a ‘good’ report (when this is not the case), the faculty has difficulty in addressing this issue as as far as can be ascertained, the student’s behaviour has been deemed satisfactory for the clinical environment in which they will eventually work!

Please note: During the GP rotation, students are also placed for 1-2 sessions at disability, dermatology & ophthalmology clinic, and after hours (evening/weekends) with a locum GP.

Year 4 nine week Notting Hill Campus teaching program

Students undertaking their GP rotation at Notting Hill will work through the course content according to the nine-week framework set out in the following table.