Two main themes of GP trainees’ self-regulation were identified: 1) self-regulation loops and 2) elements influencing self-regulation. The first theme consisted of two dimensions: a short and a long loop. The second theme included three dimensions: personal, interpersonal and contextual elements. We describe the phenomenon under study by describing the short loop, the long loop and the influencing elements, and illustrate these with quotes [42
]. Table describes the characteristics of the short and the long self-regulation loop and thereby illustrates the differences between the two loops. Figure illustrates the short and the long loop of self-regulation and the interpersonal and contextual influences hereon.
Characteristics of the short and long self-regulation loops derived from 21 interviews with GP-trainees
The short and the long loop of self-regulation, and interpersonal and contextual influencing elements.
The short self-regulation loop
The short self-regulation loop was regulated internally and occurred with problems that were relatively easy to solve. It generally lasted one week at most. Self-monitoring occurred when trainees realized they did not know how to solve the problem at hand or only knew a partial solution. This happened during consultations in both the first and third year of training, and was mostly confined to minor ailments and problems that required direct visual observation (e.g. skin problems) or immediate action (e.g. shoulder injections). When trainees realized they knew nothing at all about a problem, they generally asked their supervisor for immediate advice during the consultation.
"“…for example a skin problem that makes me wonder ‘What is this?’ What I did was ask my supervisor to come and take a look. For well, if I don’t…if I don’t recognize it, I don’t know what to put on it.” (Female, first year, P14)"
When trainees realized their knowledge was not sufficient but knew where to find the answer, they solved the problem by looking it up during the consultation (e.g. on the Internet, in handbooks) or they prescribed something they thought would help, and made a follow-up appointment. In the meantime they looked for additional information about the case. Usually, this did not require a lot of activities. Most trainees recorded these activities as ‘things to do’ either by making a mental note, a post-it note or a note in the patient record.
The learning activities undertaken by trainees in these cases focused on solving the problem at hand. Generally, the ‘things to do’ were acted upon within a week, but for some trainees they just disappeared from their attention. Most trainees looked up how to solve the problem but did not study underlying factors and mechanisms. Some trainees thought they should study these problems more extensively to gain knowledge for future cases. The trainees assessed improvement of their performance mainly by evaluating their self-confidence during the consultation,and by using guidelines or handbooks.
"“When I…when I see a patient with these problems and I am sure that I know. When a patient has these problems and I am not afraid to go on, go further and treat or refer, if you’re not afraid, or if you’re sure during the consultation, that means I know.” (Female, first year, P19)"
"“…I would say that during a consultation I automatically consider ‘What were the steps again?’ And…then…and…when I have worked that out for myself, I often check whether it was correct what I thought about the steps. And that’s really how I do it, so I use the Guideline to check whether I’m right.” (Female, first year, P12)"
Clinical outcomes and supervisors opinion during or after consultation contribute to assessment and influence trainees’ self-confidence.
"“…afterwards he [supervisor] always comes to me and then.well, at first I reviewed almost all patients like ‘I saw this, I saw that, would you also do it that way?’ or ‘is this right?’ And now I only talk about patients when I have a question about them.” (Female, first year, P22)"
Short-loop learning was not documented in the learning portfolio nor did it involve usage of results of external mandatory assessments as a starting point for learning or to assess competence.
The long self-regulation loop
The long self-regulation loop was internally regulated but could also be affected by external regulation during the day-release programme. The long loop was generally spread out over a longer period of time, and, unlike the short loop, was used with complex or recurring problems requiring more learning activities. Monitoring occurred during the consultation, when complex problems (e.g. suspected child abuse, cardiac problems) were identified, and also after the consultation when the trainees looked back purposefully over a longer period of time to identify similar recurring patient problems (such as difficulties interviewing patients with psychological problems) or organizational problems (e.g. time management).
"“…are more structural things, about which I suddenly feel ‘I don’t get enough out of just seeing these patients, I have to do more’. So I have to make a learning goal and I think…well, at least that’s what I understand and that’s also how I see it, how I experience it, that’s the purpose of learning goals, and that’s the way I try to use them to do something more with them.” (Male, third year, P18)"
Long loop self-regulation of first-year trainees mainly related to communication problems, whereas with third-year trainees it occurred with problems like child abuse, terminal care, cardiac or asthmatic problems or (time) management. Compared to short loop self-regulation, long loop self-regulation was more likely to involve planning of learning activities. Multiple activities were undertaken to solve the problem in question, such as consulting the supervisor, the literature, handbooks or the Internet. The trainees also asked mentors and peers of their day-release group for advice on how to proceed when a problem was difficult to handle or had a strong emotional or personal effect on them.
"“… a child with an unusual wound and the mother telling a strange story that made me think … it was a burn and I thought of child abuse. I talked about it with my supervisor and he said ‘Well, it’s just once … we won’t do anything about it’, but I kept worrying and I wanted to follow it up. Then I thought ‘well, this….well, I actually don’t like this at all’, so I called the paediatrician who is also treating the child. And because my supervisor did not want to do anything, I thought ‘Well, what should I do?’ So I discussed it in the group and everybody said ‘yes’, including the paediatrician, and all the other trainees in my group said ‘Yes, you really should report this to the Office for the Prevention of Child Abuse. When I reported this to my supervisor like, ‘listen, this is what the paediatrician and my peers advised me, and I am not o.k. with it, so I want to report it’. And he said ‘Yes, yes, all right, you do that, I’ll back you up’. So that's what I did…” (Male, third year, P16)"
Improvement of performance with regard to these problems was mainly assessed by the trainees in terms of self-confidence based on confirmation by clinical outcomes or by the supervisor, mentors or peers. The long loop was impacted by external regulation when external mandatory assessments revealed shortcomings trainees had not discovered for themselves. In this respect, the trainees especially valued the communication video assessments, as these provided concrete feedback and learning goals, encouraging them to plan learning activities. The trainees also valued the progress meetings, because these enabled them to discuss their progress and learning plans. The trainees made hardly any use of the results of the knowledge tests for their learning, because these tended to vary over time regardless of trainees’ study efforts, and were therefore considered to be less relevant. Several trainees mentioned that the external mandatory assignment to formulate learning goals promoted self-monitoring, encouraging them to consider learning goals they might otherwise not have formulated. Learning as a result of the long self-regulation loop was more likely to be included in the learning portfolio than short-loop learning.
Facilitating and impeding elements
Elements influencing self-regulation could be divided into three dimensions: personal, interpersonal and contextual elements. The main personal element consisted of trainees’ intrinsic motivation to become a good doctor, which was a strong driver of self-regulated learning.
“And I also think.I feel it's my sense of responsibility that as a GP …I have to keep up, have to know whether…that’s really coming out of myself, and that…I don’t think that that is an idea that is coming from others.” (Male, third year, P3)
Personal elements that were barriers to self-regulation and learning were concentration problems, dealing with too many tasks at the same time or general problems in dealing with negative feedback. Most trainees found themselves active learners, but a few considered themselves passive learners, tending to postpone learning activities or only engaging in them when prompted to do so by others. As for interpersonal elements, trainees reported being stimulated and inspired by their supervisor and the mentors of the day-release programme. Most trainees were very enthusiastic about the way their supervisor encouraged them to find things out and discussed patient problems with them, and by their supervisor’s commitment to their learning.
"“It helps if…well, I like to be stimulated to learn things, and that may happen during the day-release meeting, because of the planned programme, or because…because someone says ‘Hey, I also wonder how that works, shall we look into it?’ Then it’s a shared question. That stimulates me.” (Female, third year, P5)"
Unfortunately, some trainees did not experience this type of stimulation and inspiration, which may be due to differences between supervisors. They mentioned a distant or poor personal contact with the supervisor. Two of them experiences even a lack of supervision and felt unable to influence this.
"“I think I do not get enthusiasm and structure from my supervisor, especially enthusiasm, it’s not motivating. Look, you can also have a supervisor who says ‘Well, go and find out about that’ or ‘maybe we can work on that together’. And, well that just doesn't happen, I have to take the initiative. Well, that doesn’t help.” (Male, first year, P15)"
Most, but not all, trainees also reported being stimulated by the mentors of the day-release programme. Trainees felt inspired by their peers as a result of sharing problems and similar experiences. The most stimulating contextual element on learning was related to patient encounters, which were not only an incentive for trainees to look things up or plan learning activities, but also had a strong impact on trainees’ retaining knowledge and experiences in memory. Other contextual aspects were characteristics of GP practices, such as the presence of certain types of patients, organizational aspects and a positive working climate.
"“…it did help, I think, that the practice assistants were willing to support me, it can work against you if the assistant doesn’t want to change the schedule. Luckily it went well this time, so they think along with you. So that helps.” (Female, third year, P1)"
Factors that were seen as barriers to self-regulation were time pressure, the absence of certain types of patientsdifficulties in planning learning activities,
“Only… it happened quite often that the coaching sessions on Thursdays were cancelled for some reason or other, so that was something, and in the end we rescheduled these sessions, for they were always Thursdays from 5 to 6 pm, and then from 6 to 7 pm, well, then I’m not really motivated, she also wanted to go home, so now we meet in the morning, at the end of the morning, and yes, that’s much better, and there’s time reserved for it, that's quite nice.” (Male, third year, P15)
and trainees' inability to change practice routines that hindered their learning.
A contextual aspect relating to the day-release programme was the positive atmosphere, although some trainees felt this could be improved. Some trainees mentioned difficulties combining tasks related to work and private life.