# 2009 Radcliffe Publishing Limited
Simulating doctors: a report on a workshop training actors to simulate general practitioner appraisees and general practitioner registrars Johnny Lyon-Maris BSc MMEd FRCP MRCGP Associate Director in Postgraduate GP Education, NHS Education South Central Peter Burrows BM BCh FRCGP Former Convenor and Developer of the MRCGP Simulated Surgery
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can experiment with different approaches in a protected and professional environment. They also bring the advantage of a predetermined problem with specific learning outcomes in mind. Actors can also be used for appraiser training to simulate GP appraisees in difficulty. In particular, training is needed for appraisers to deal with appraisees who are reluctant to engage with the appraisal process.4 Scenarios were therefore developed for both simulated GP registrars and appraisees in difficulty. We have concentrated on attitudinal problems, which present a particular challenge to trainers and appraisers.
AIMS AND OBJECTIVES The aims of this workshop were:
Keywords: appraiser training, simulated appraisees, simulated trainees, training the trainers
INTRODUCTION ‘I am not a teacher: only a fellow traveller of whom you asked the way.’ George Bernard Shaw, Irish dramatist, novelist and critic (1856–1950) Using actors to simulate patients is standard practice in undergraduate and postgraduate medical education.1 Patient simulation has also become a standard assessment tool in postgraduate medical education as part of the new MRCGP clinical skills assessment.2 The UKCEA conference (2006) in Brighton hosted a workshop3 demonstrating the use of actors simulating general practice (GP) specialty training registrars in difficulty, as a way of stretching trainers at experienced GP trainers’ courses. Traditionally in Wessex, GP trainers have attended three-yearly update courses. The courses are residential and three days in length. The format of the courses has changed very little over the past ten years, with GP registrars attending on the middle day for teaching practice. Experienced trainers have evaluated these courses as repetitive and not enhancing their knowledge, but value the courses highly as a sharing and networking experience. GP registrars bring with them their own agendas, and there may be issues of confidentiality involved. Trainers feel inhibited in testing new teaching techniques, for fear of upsetting the learners. Real registrars do not usually bring attitudinal problems; however, these are important to address and trainers need the opportunity to learn how best to handle them. Simulated GP registrars are a safe alternative, whereby trainers
1 to identify and train a cohort of actors to simulate GP registrars and GP appraisees 2 to provide NHS Education South Central (NESC) with a bank of simulated GP registrars and GP appraisees available for experienced trainer courses and GP appraiser workshops. Our objectives were: 1 to develop four GP ‘registrar in difficulty’ scenarios and four GP appraisal scenarios for use with simulated doctors 2 to recruit and train six actors to be able to play these roles in interviews with trainers and appraisers 3 to familiarise the actors with the training of GP registrars, the day-to-day work of GPs and the system of GP appraisal 4 to train facilitators to use this method in experienced trainer workshops and GP appraiser training and introduce the actors to different facilitator styles.
METHODS Funding was provided by NESC, following a bid by the authors. A series of eight scenarios were developed with the help of trainers and appraisers. Personal experiences were drawn upon, to make the scenarios lifelike and easily recognisable by the educators. The scenarios were modified after use at the workshop, according to how they had performed. The lead actor, who had worked with the authors in a previous pilot, identified five colleagues whom she felt would be interested and appropriate for the project. They were invited to attend a two-day residential workshop in Southampton facilitated by the authors and the GP appraisal lead for Hampshire Primary Care Trust (PCT). Session one consisted of introductions and an
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explanation of how GPs are trained from the start of medical school until they are licensed to practise as a GP. The facilitators explained the day-today work in general practice and how GPs are paid (stressing that general practice is a business). An explanation of the GP appraisal system was given, outlining the requirements placed on the appraisee to provide evidence about their personal practice and the confidential relationship with their appraiser. The lead actor spoke about the techniques of simulating doctors. The majority of the actors had experience of simulating patients and two had simulated GP registrars before; she had also simulated experienced GPs. In her experience it was not hard to acquire sufficient ‘medical speak’ and background to pass for a GP. She reassured them that learners would be briefed not to challenge the medical knowledge of the simulator. The actors were given an explanation of what a GP trainer does, what happens on an experienced trainers’ course and how trainers are reapproved. They learnt that GP trainers find that knowledge and skills can easily be taught to registrars, but that attitudes are very difficult both to teach and to change. All the scenarios are therefore designed to provide the trainers with experience in this domain. (An example is shown in Appendix 1.) The authors and lead actor then demonstrated how simulated GP registrars had been used in a previous pilot. This involved simulating a tutorial between the trainer and registrar in the presence of a small peer group of trainers. One of the authors facilitated the scenario, whilst the other acted as the GP trainer. The facilitation process involves freezing the action at relevant points, stimulating discussion by the group on what they have seen, asking ‘how can we take this forward?’ and seeking views from the group. When a member of the group comes up with a solution, they can be asked to take on the trainer’s role to test this approach with the simulated registrar. Session two – whereas the GP registrar scenarios require only a briefing for the actor and an overview for the trainer, the appraisal scenarios also require some documentation for the appraiser, to make the interview realistic. This is done by providing the relevant parts of ‘Form 3’, supported if necessary by items of evidence. These are provided in advance to the appraiser (and the group observing), as they would be in a real-life appraisal. They contain cues to the appraisee’s problems, and this allows the appraiser time to decide how they will approach the area of difficulty. The actor’s briefing also contains suggestions as to how they should respond to different approaches from the appraiser (see example in Appendix 2). In this session the actors practised simulating established GPs undergoing appraisal, using two of the scenarios, with the authors acting as the appraiser and the facilitator. Session three – this session returned to the GP registrar scenarios. Some tutors from the experi-
enced trainers’ course attended this session and learnt how to facilitate the scenarios using the simulated registrars. Session four – this session was used to learn and rehearse the last two GP appraisal scenarios. There was then a general discussion of the process and feedback from the actors on their experience of simulating doctors was sought. Adjustments to the scenarios and documentation were also suggested.
RESULTS The two-day workshop led to a good understanding by the actors of what is necessary to simulate a GP registrar and an established GP. NESC now has six actors available to them for experienced trainers’ courses and GP appraiser workshops.
The simulators The authors’ impression was that the actors seemed very capable and rapidly learnt what was necessary. They said that the GP background and doctor language were initially a concern for them, but they acquired enough knowledge to be able to manage the interaction without it becoming an issue. We reassured them that the trainers and appraisers would be instructed not to challenge them on clinical problems. The actors said they would prefer to arrive at the groups in role and not interact socially with the doctors before the interviews. The process of freezing the action and recommencing with a different doctor presented no problems for them. The simulators provided feedback to the doctors both in and out of role. They liked giving feedback in role and understood the purpose of it. They preferred not to give feedback out of role until the interview had ended. We adopted the convention of addressing them by their role names to request feedback in role and using their own names when asking them to give personal feedback.
The documentation The simulators were happy to have concise briefing documents. They wanted a summary of the doctor’s personality, the concerns that the doctor had and the agenda that they needed to bring to the encounter. They were happy to receive direction from the facilitator on the intensity of emotion, resistance or arrogance they should bring to the role and they could adjust this to suit. They wanted to have some indication of how long to maintain it and the appropriate threshold for moving towards compliance. There was discussion about whether it was better to put the crux of the scenario up front or allow the trainer/appraiser to tease it out.
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In the appraisal scenarios we found a need for a small amount of background to be provided, e.g. ‘The practice is semi-rural with five partners and Dr X joined the partnership two years ago’. The facilitator needed to frame the interview for the appraiser, for example by saying ‘You have dealt with last year’s PDP and Good Clinical Care, and now you want to address the section on Maintaining Good Medical Practice’.
The facilitators The authors found that the technique of ‘freezing’ the action at sticky moments, seeking peer discussion of the way forward and substituting another member of the group to take up the trainer/appraiser’s role was very effective. It kept up the attention of the group, harnessed their ideas and provided an immediate opportunity to implement them. It was also possible to ‘rewind and replay’ the action in a different way (e.g. more or less confrontational) and see what the simulator’s response would be. In our experience of the pilots, the maturity of the trainers allowed this swapping in and out to enhance their creativity in finding solutions. No doctor felt ‘picked upon’ and all of them engaged with the process. The course tutors who attended Session three used the technique in different ways to bring out the different learning agendas that they wished to pursue. The lesson that we have drawn from this is not to make the scenarios too prescriptive towards a particular outcome. The combination of the actors’ improvising skills and intuitive responses, with the capability of the trainers to understand the dynamics of a situation, provided insights that were unforeseen by the scenario authors. Facilitators too have to venture beyond their comfort zones!
DISCUSSION What the Wessex Deanery has done with these simulated doctors is not unique, but is certainly pushing the boundaries of GP trainer and appraiser development. Wessex has adopted an idea put forward by other deaneries and turned the concept into reality. The authors have taken the simulated GP registrar to another level and applied the technique to GP appraisal. The authors aim to broaden the skills of trainers and appraisers by placing them in challenging situations but allowing them to practise in a safe environment. The Wessex experienced trainers’ courses have now been redesigned with simulated GP registrars in mind. On the three-day residential course, day two will be dedicated to simulation. If
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there are the three groups we shall have four simulated GP registrars – three of them to provide one scenario each, rotating around the groups at scheduled intervals, while the fourth acts as an observer. We have a duty to develop the actors’ experience of simulating doctors and we intend to use their input to develop further scenarios. Hampshire PCT will be using the simulated GP appraisees in an appraiser training workshop and feedback from this will guide the way that GP appraisee simulators are used in the future. We hope to make them available for the training of appraisers throughout NESC, which is taking on this responsibility in 2009.
CONCLUSIONS AND RECOMMENDATIONS With funding from NESC, Wessex has recruited and trained a group of ‘simulated doctors’ for use in experienced trainers’ courses and GP appraiser workshops. It is envisaged that the bank should be used by both Wessex and Oxford Deaneries and could be made available to other professions within NESC for professional development.
Acknowledgements Thanks to Dr Eileen Gorrod for co-facilitating this workshop; to Dr Mary Davis for her help and permission to adapt the GP trainee scenarios; also Dr Eileen Gorrod, Dr Margaret Keightly and Dr Peter White for writing scenarios for the simulated GP appraisees. The workshop was funded by NESC.
References 1 Bradley P (2006) The history of simulation in medical education and possible future directions. Medical Education 40: 254–62. 2 Wakeford R and Patterson F (2006) The MRCGP Clinical Skills Assessment Standard Setting and Related Quality Issue. RCGP/COGPED Assessment Group: London. 3 Davis M (2007) Use of Simulators in Developing GP Trainer Skills. http://gp.kssdeanery.org/ukcea2007/workshops.php (accessed 13/09/08). 4 MacLeod S (2007) The development of a tool to help when dealing with non-engagement in a GP appraisal. Education for Primary Care 18 (1): 95–100.
Correspondence to: Johnny Lyon-Maris, GP Education Unit, Education Centre, Mailpoint 10, Southampton General Hospital, Southampton SO16 6YD, UK. Tel: +44 (0)23 8079 6751; fax: +44 (0)23 8079 5008; email Johnny.
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Appendix 1 EXPERIENCED TRAINERS’ WORKSHOP Scenario Name:
Simulator background As a GP registrar you have been working in the practice for two months having had previous training in general medicine. You decided that the career opportunities in GP, as a GP with a special interest, were greater than continuing training in general medicine. Your approach to GP is very medical, that is to say that there is a diagnosis for every illness presented, and you are unhappy to let patients go without many investigations to confirm a diagnosis. If the first batch of investigations does not reveal a diagnosis you do another batch. Your surgeries are full of patients that you have already seen and are currently investigating. You are unhappy not following up patients unless you have made a confirmed diagnosis. You feel that some GPs in the practice, when sitting in, are not very thorough, and have often heard them say ‘I do not know what you have got’. Professionally you do not feel this is good practice, and perhaps you need to discuss their poor diagnostic skills and lack of attention to detail with your trainer or programme director. You have heard from the staff that the patients like you and consider you to be a very thorough doctor. You are just about to have a tutorial and were going to mention your concerns today.
Trainer background Your GP registrar, who has come from a general medical background, has been with you for two months. They are on 15-minute appointments, but you notice the same patients are filling their surgeries, and the GPR is doing a vast number of investigations on the patients, some of which you have never heard of. This is many more than previous GPRs at this stage of their training. You are just about to start a tutorial and were going to bring this up with them.
Appendix 2 SIMULATORS’ BRIEFING – DR ROBIN WALKER – THE ‘RELUCTANT LEARNER’ You are in your early 40s. You are the third partner in a five-partner practice with a list size of about 9000. Your children are both at private schools. You enjoy sailing and have recently taken up golf. You have not been a trainer although the practice does have a registrar. You feel well settled in your career and see yourself staying put until retirement. You have fallen out of the habit of continuing your medical education. You find that you have accumulated enough experience to cope with everyday practice without having to constantly update your knowledge. You feel that the basic rules of medicine don’t change that much and you have had no complaints from patients about the standard of your practice. You are not really interested in education and think that much of the new stuff is mere medical fashion. You get most of the information you need from the drug company reps whom you see in surgery, and you sometimes go to their sponsored meetings (especially if there is a good meal provided). You have been to a couple this year – if asked, you recall that one was about a new drug for migraine, but you can’t remember what the other one was about. You prefer listening to a good lecture rather than going on a new-fangled course where you are expected to participate. You read the GP magazines, but not the serious stuff like the BMJ. You haven’t tried any of the online learning programmes that some of your partners use. You were relieved when the Postgraduate Educa-
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tion Allowance (PGEA) came to an end three years ago and you no longer had to accumulate credits for attendance at meetings to earn your full salary. Initially during the interview you should express a string of views about the benefits of experience and how this is not acknowledged by your colleagues and the GP tutors. Emphasise that none of your patients have complained that you are not up to date. You staunchly believe that you can be a good doctor without needing to spend hours brushing up your education. To be honest you’d rather spend your precious leisure time with your family or sailing your boat. As the meeting goes on you should gradually look at the potential for other methods of learning and reflection on your work. You are partly argumentative, partly listening to your appraiser’s suggestions, but only if these are constructive comments, and not personal criticism. If well handled you will agree to set some modest objectives for your education next year. If not, you should remain resistant.
Appraisal Statement: Form 3 – Dr Robin Walker Maintaining good medical practice Commentary – what steps have you taken since your last appraisal to maintain and improve your knowledge and skills? I have been in practice for 12 years and feel I have seen most things. Experience is the best way of maintaining one’s knowledge and skills. I have been to a couple of good drug-sponsored meetings this year, which were interesting; certainly the food was good! I like the old-fashioned way of being educated such as a good lecture from an expert. Nowadays, courses seem to consist of all this touchy-feely small group work and navel gazing, which I find irritating and of no benefit to me. I look at the GP mags. Sometimes they have useful reviews of clinical conditions. I get most of my information from the drug reps, who always seem to be up to speed with the latest information and give a well-balanced opinion of things. There does not appear to be anything really new, certainly nothing radical that affects the way I practise, apart from QOF, which has obviously changed some of the ways we do things. I have not had any complaints about my prescribing or the quality of my care. I feel I practise good medicine and my patients seem to agree. I have not done any of the online learning programmes that my partners keep telling me about. I spend more than enough time on the computer at work! We have practice meetings, which I attend. The younger GPs put forward lots of new ideas but on the whole I do not take a lot of notice of them as I feel they are just trying to keep up with the latest fashions in medicine. What have you found particularly successful or otherwise about the steps you have taken? As I said above, I like a good lecture and if it comes with a good meal, so much the better. What professional or personal factors significantly constrain you in maintaining and developing your skills and knowledge? Nothing. I feel that I am up to date and do not have any real learning needs. How do you see your job and career developing over the next few years? Carrying on the same as I do now. My patients would not like me any other way and they probably know better than any governmental body.
