I talked to 19 past registrars I had trained between 1983–2003. As part of a larger project, we discussed their memories of GP training, and I asked them how they might characterise our trainer–registrar (trainee) relationship. We came up with the following analogous duos:
The Lone Ranger and Tonto (Galloping off together to fight disease with silver bullets).
Inspector Morse and his sidekick Lewis (‘Another beer, sir?’).
Batman, and Robin the Boy Wonder. (Gotham City is a dark and scary place).
Byron and Shelley (‘A restless hedonist peer, and a more socially minded but doomed rebel’).
Detective Sipowitz in NYPD Blue (Imperfect heroes, working above and below the rules to do the right thing). The second part of the duo wasn't defined. Was he another detective — or perhaps a perpetrator?
Asterix and Obelisk (Irreverent, anti-establishment cult folk heroes, undermining Blairite central (Roman) authority. One is stoutish).
Old Scrooge and Bob Cratchit (‘… working by the light of a single candle, oppressed, and forever wanting to be allowed to go home’).
Willy Wonka and Charlie Bucket (‘Charlie was a kid from a very poor family who loves chocolate. He gets the golden ticket and he goes into Willy Wonka's Chocolate Factory which is just the most amazing place, Willy Wonka's this slightly eccentric chocolate factory owner who has got all these amazing rooms where the most amazing things happen, and the river of chocolate, and the Umpa Lumpas …’)
Luke Skywalker and Yoda (The fledgling warrior, and the small green guru with pointy ears).
Female/male duos seemed less easy to imagine, but some more complex models emerged.
Thelma and Louise (‘I'm the wayward one whereas you're the clear head … but we both go over the cliff together’.)
The Avengers (‘Steed and Emma Peel, he's got the old Bentley… she gets to sort out all the muddles’).
Professor Higgins and My Fair Lady (‘Yeah, when she throws the slipper at him’.) (Pygmalion syndrome addresses how human personality is constructed, the competing desires for autonomy and certainty — not irrelevant to GP training). ‘I don't think ours was ever a parent–child relationship, actually. That was very clear from quite early on, that you were not going to be my parent and I asked you to be sometimes. I remember once saying, look, I just want you to tell me the answer to this problem, I'm very busy, and just for once don't ask me what I think about it … just tell me, I need to get on! And you might have laughed, but I was so frustrated with it.’
In his 1982 book Training for General Practice Denis Pereira Gray described a variety of possible types of relationship, based on 13 of his own trainees and 100 others from the Exeter scheme.1 He defined the following (overtly authoritarian) duos:
Animal tamer (Making them jump through the hoops).
Puppet on a string (Trainer controlling every action of the registrar)
Driving instructor (Impersonal teaching of specific skills).
Military model (As in hospital grand rounds).
Producer–Actor (Trainer adding depth and coordination to an individual's performance).
Parent–child (With risks implicit of not playing ‘happy families’).
Older sibling (The big brother or sister relationship; may involve sibling rivalry).
Doctor–Patient (Initial dependency, evolving into autonomy and even partnership).
Twenty years on, my trainees and registrars described less authoritarian (and more irreverent) duos. GP training has become progressively more structured with Summative Assessment and the growth of organised VTS activity. The term ‘trainee’ now sounds archaic, and has been replaced by the more hierarchical term ‘registrar’. ‘Trainer’ however is still in favour, and despite technological escalation, one-to-one apprenticeship remains highly valued at the core of GP training.
The models my registrars described included heroic quests, mutually subversive attitudes to the system, recognition of human imperfection, detective work, deflation of pomposity, hidden agendas, magic realism, and science fiction. Sex differences were apparent; my women registrars described more complex relationships with subtle undertones. The male/male models, though less authoritarian than those described by Dennis Pereira Gray, were often not on an equal basis.
Why are these relationships not those of equal adults? One ex-trainee reflected on today's registrars: ‘While they're not passengers in their own lives, they are so child-like in their training in hospitals that it's unrealistic to expect them to leap into this adult relationship that we had in that year, because they can't do it. They can't even work without being supervised in hospital. It would be cruel of us to ask them to leap into that place.’
What sorts of current working relationships do other trainers and their registrars recognise — and what should we aspire to as their educational mentors? The GP training year has evolved from a traditional apprenticeship, focused on practice-based skills, to contain the obligatory, externally imposed hurdles of Summative Assessment. GP Registrars now may never become a partner, deliver a baby or visit out of hours, but will need to perform to an elaborate quality agenda and succeed with lifelong learning via appraisal and revalidation. Faced with these requirements, how will trainer–registrar relationships mutate further in the new millenium?
Notes
Funding
Grant from RCGP scientific foundation (SFB/2004/01)
- © British Journal of General Practice, 2005.
