Nearly half the GPs interviewed described how the stress of balancing teaching with service had this affected them and GPs identified a number of factors contributing to the stress of teaching. In particular, at times they could be
overwhelmed by the added time needed to teach in an already busy clinical day. Having people sitting in is great. I think it's a great thing to do but it
slows you down and if you are going to make it worthwhile … it's needs to be a conversation. And that’s fine if everything's a bit relaxed but once it gets tense…it's the potential isn't it? You’re almost frightened of the tidal wave, even if it's not there, but you know you couldn’t cope if it was. That in itself becomes a little bit frightening. (M9) One tutor describes trying not to let the student realise the impact of their presence in their surgery.
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I think if there is someone on holiday and there is only two of us here, I have found having the medical student makes me late and I
internally find that frustrating. I try and not to externally express that but sometimes that’s probably unavoidable. I try not to because it's not their fault and we’ve agreed to have [them] so I just need to kind of suck it up. (F7)
Some have taken measures to try and address this pressure by adding more structure and protected time to their day. This was discussed in 7.5.2.1.
From an undergraduate point of view, the intensity of teaching varied with the seniority of the student. Several 3rd year tutors described their intensive teaching days as more exhausting than having a year 4/5 student attached.
The 3rd years, although they are not here much, they are quite time consuming … because they…follow you around a lot more. They need a lot more encouragement to do things and a lot more time spent with them... So, although they are only here for a few days…once a [fortnight] for [7 days in total] … I think that they are quite draining days. (M4)
In contrast to postgraduate training, the fact the students weren’t there all the time did at least provide some respite from the intensity of teaching.
I think it's less of a … commitment. It is quite intense while the students are here but it's not … an all year long thing… It's not constant [whereas] the training obviously is and I think there’s not… as much involved in [teaching students]… in terms of assessment and formal teaching. (F5)
While protected time for teaching has been described, it is recognised that some GPs undertake activities that support teaching in their own time. Examples given included chasing trainees for e portfolio entries, reading e portfolio entries or planning teaching activities. Overall, this appeared to be more of an issue from a postgraduate point of view. GPs also identified the challenge of balancing their teaching with other practice activities requiring their time e.g. management activities.
A significant stressor to a practice and a trainer can be a struggling learner, in particular a struggling GPST. Practices anticipate and plan for new FY2s and ST1s
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needing significantly more input and support but expect them to progress and become more “valuable” as time progresses.
When the trainees first come into the practice…they shadow
everyone. They get a chance to sit in with everyone or go out on the calls… So for the first month when they are here there's quite a wee bit of chat, especially for the ST1s…the ST3 maybe less so but still a little bit in the first week or two. (F5)
Obviously you want your ST3s to get to a point where they are [like a] fully-fledged GP and doing exactly what everybody else does or
they're failing. (F6)
Those practices that took FY2s commented on the marked difference between those allocated to the first rotation of the year and those allocated at the end.
They tend to get a lot more confident as the year progresses. We noticed like by the third round of FY2s during the year they are a lot more confident and know what they are doing a lot more because they tend to have done general medicine and stuff. (F1)
Therefore, the impact of a struggling trainee is two-fold: they require additional resource in the form of support and are unable to contribute to service as had been anticipated.
This has involved a lot of intense work by our trainers putting in extra time, teaching, [tutorials], reviewing notes, following up (M1)
From their descriptions, it is clear that some of the GPs emotionally invest in their learners. GPs can experience guilt at having to fail learners but also satisfaction when they help a struggling learner progress.
I had one time where I had a failing student and I had to fail him at the end of his block [due to a probity issue]. I felt terrible about that because it meant he was going to fail his whole year and had to repeat a year. (F7)
The student described in this example subsequently returned to the practice as an FY2. The GP described being puzzled when she realised he had been
allocated to come back but on returning, he thanked her for failing him. He had been unwell and failing his attachment had been the trigger for him getting
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help. He had requested to return to the same practice to prove to the GP how he had progressed since she last saw him.
The emotional impact of working with a struggling or challenging learner can also include frustration, most commonly when there is a professionalism concern or learner disinterest.
I’ve never had a student that’s been problematic in terms of
performance but I have had a few that I’ve not particularly enjoyed because they’ve not been interested… and I found that very
frustrating… I don’t care whether people don’t want to become general practitioners, that’s perfectly understandable, but I want them to be interested because what we are doing here has lessons for every young doctor, whatever speciality. (M1)
The possibility of teaching precipitating burnout was the most concerning emotional impact of teaching raised. For one GP, this appears to have been exacerbated by the current context of General Practice which was explored in 0.
I sometimes…worry… because I do so much, whether, I’ll burn out from it…I think having a break every so often would be a helpful thing. That’s one of the things when we first started teaching…there was three of us that would take year 3 and two would take one year and there would always be one person that didn’t take. The way the practice is at the moment everybody’s taking every year, so it’s not quite gone to plan. (F3)
Another GP described the impact when one of their fellow trainers had been struggling to function as a trainer and a GP. As well as coping with the additional workload pressures, the GP interviewed also had to manage the impact on
teaching in the practice and the personal impact of the situation. We had a partner who wasn’t functioning very well and… he was a great guy and all the rest of it but essentially he wasn’t writing anything in the notes… So we’d have whole empty surgeries with nothing written and he was a trainer too so it was quite awkward and difficult. (M9)
7.6.2.1 Activity Theory interpretation
Although the stress of teaching is often a result of the primary contradiction between teaching and service, further factors can increase the pressure on the teacher. Learner characteristics (e.g. struggling learner) can create a secondary
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contradiction between the subject (learner) and the object (teaching) which may impact on the division of labour for an individual GP and their practice. Mapping allows identification of tools which may help identify opportunities to alleviate tensions. (Figure 7-23)
Figure 7-23 Factors which can contribute to the stress of teaching in multilevel learner practices and tools which may help alleviate the stress