Empowering GP registrars as near-peer teachers in general practice: a mixed methods exploration of a co-designed intervention

Empowering GP registrars as near-peer teachers in general practice: a mixed methods exploration of a co-designed intervention | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Empowering GP registrars as near-peer teachers in general practice: a mixed methods exploration of a co-designed intervention Hok Lim, Daniela Ramirez Duran, Anneliese Willems, Rebecca Starkie, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7379385/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective GP registrars are an underutilised resource within the GP and medical student education. While many GP registrars informally contribute to the training of future doctors, their provision of teaching is often unstructured and ad hoc because of the lack of formalised pathways for teaching. Near-peer teaching, where a learner teaches another learner at a more junior or similar stage of training, offers an approach that can enhance both teaching and learning experiences. This study aims to provide a framework for GP registrars to teach with the goal of integrating and scaling this approach within GP training. The study evaluated the impact of providing registrars with teacher training and the impact of the resulting teaching activity on stakeholders. Methods and Analysis The study was conducted in two sequential phases. Phase 1 used a small group of participants across three stakeholder groups: GP registrars (n = 8), GP supervisors (n = 5), Medical students (n = 7) to codesign a pilot intervention that included teacher training and teaching opportunities. Data was collected using focus groups and surveys. Phase 2, used iterative feedback to optimise and implement the intervention with a larger group of GP registrars (n = 18). Data was obtained from surveys. We used reflexive thematic analysis and descriptive statistics to analyse data from both phases. Results This study illustrates a real-world application of GP registrars engaging in near-peer teaching in a supported and semi-structured manner. This study revealed three key themes. 1. Evolution of an educator identity, 2. Workflow integration, 3. Stakeholder collaboration. As a result of the project, the GP registrars reported increased confidence, competence and the development of dual professional identity as clinicians and educators. While there were some trade-offs, such as time and financial considerations, the teaching experience and professional development were generally valued by registrars. Medical students and other learners also valued the diverse teaching styles provided by an expanded teaching faculty. GP supervisors reported neutral or positive effects on their workflow and stress levels. Conclusions Structured guidance and support can encourage and enable GP registrars to successfully teach near-peers in the primary care setting. Clearer renumeration pathways may further incentivise GP registrars to participate in near-peer teaching. Central training organisations can play a pivotal role in facilitating broader rollouts or trials and promote the development of teaching skills as an integral part of GP training. Such initiatives not only enhance the educational experience for medical students but also contribute to the professional development of registrars and the overall quality of primary care education. Near-peer teaching GP registrar education medical student learning general practice training Key Messages What is already known on this topic – Near-peer teaching experiences provided by GP registrars assist in solidifying their own learning and serve as a foundation to achieve core competencies within their GP training curriculum. Their involvement in the primary care teaching workforce has shown a favourable impact on engagement and perception among medical students regarding general practice. However, it is noteworthy that when GP registrars undertake teaching responsibilities, it is frequently conducted in an informal and ad hoc manner, lacking structured frameworks or formalised processes, and thus GP registrars are seldom utilised or incentivised to be a core part of the primary care educational faculty. What this study adds – The provision of brief formalised teacher training sessions and supported teaching activities can develop confidence, competence and identity as an educator for GP registrars. Registrars can formally play a greater role in medical student or other near-peer teaching during their training. How this study might affect research, practice or policy – The learnings and structure of this co-designed intervention could be scaled more broadly. A structured teaching program, clearer funding policies and stronger institutional supports can facilitate and promote GP registrars as educators in the primary care clinical setting. This project provides a transferable framework for a broader roll out and could be integrated into current GP training in a variety of contexts, providing benefits such as an improved GP registrar professional development, a diverse educational faculty for the profession and better engagement of medical students in general practice. Introduction The training of general practitioners (GPs) remains critical to ensuring a sustainable and effective healthcare system( 1 ). The role of GPs as educators of this workforce can enhance learning experiences for medical students and strengthen general practice as a career choice ( 2 – 4 ). Universities have expanded student placements in primary care to address GP workforce shortages ( 5 ). However, high-quality placements are necessary to encourage greater numbers of medical students to enter general practice ( 4 ). Traditionally, medical student education in the general practice setting is conducted by qualified GPs ( 6 ). GP registrars, also known as GP trainees or general practice residents are known to play informal roles in the training of medical students in the clinical setting ( 7 ). This concept is known under the umbrella of ‘near-peer teaching’ where a learner teaches another learner at a more junior or similar stage of training (e.g. GP registrars teaching medical students). Near-peer teaching has been found to improve medical students’ perception of general practice as a career choice ( 3 , 8 – 10 ). Near-peer teaching operates within the broader framework of multi-level learning (or vertical integration of learning), which incorporates different levels of learners, including medical students, GP registrars, and supervisors. The adoption of multi-level learning strategies can also benefit GP registrars, by providing an improved understanding of clinical knowledge, and opportunities for professional development ( 3 , 11 , 12 ) and supervisors, by having a shared teaching load ( 3 ) and improved workflow ( 6 ). GP professional colleges in countries including Australia, UK and Canada GP curriculum recognise that teaching is a core competency for all GPs ( 13 – 15 ). However, strategies to develop teaching competencies in GP registrars during vocational training are limited ( 16 ). Although teacher training courses are available ( 17 , 18 ), these come at significant costs, posing a barrier for early career GPs, who are already facing other significant financial and time pressures ( 19 , 20 ). There are a relatively small number of opportunities within GP specialty training programs to gain formal teaching skills ( 21 – 23 ). For example, the AGPT (Australian General Practice Training Program) Academic Post Program has 20 positions for GP registrars nationwide ( 15 ). From a pool of 39,449 registrars ( 1 ). Most teaching opportunities for GP registrars are therefore circumstantial, unplanned, and unsupported, often sidelining registrars who may otherwise embrace teaching as part of their professional identity ( 16 , 21 ). Our goal was to co-design a model with GP registrars that could help them develop teaching skills, while positively impacting the learning environment within general practice. Co-design was used to ensure that the model was relevant and practical for GP registrars, while encouraging key stakeholder engagement. A secondary aim of the study was to explore how near-peer teaching could expand our teaching workforce and provide insights into the process of training doctors to become clinical educators. Thirdly, we aimed to create a model for supporting near-peer teaching that was scalable at a state or national level in Australia. This study builds on the learning of the Integrating Registrars As Clinical Teachers (INTERACT) project in 2003, which provided teacher training to a small number of highly committed GP registrars who wanted to teach medical students ( 24 ). Materials and Methods We used a sequential mixed method research design with two phases. The iterative approach was designed to address practical challenges in GP education and empower participants through a participatory approach ( 25 , 26 ). In both phases we collected qualitative and quantitative data, with the qualitative component being more prominent. In this study, ‘GP registrar’ refers to participants enrolled in the RACGP AGPT program. Separate focus groups were conducted for each participant group, ensuring that participants could share insights freely within their peer group. Open-ended questions encouraged rich, detailed responses to allow us to construct deep themes. Open-ended questions were also included in surveys administered through Qualtrics for each stakeholder group, allowing participants to elaborate on their views and experiences in a more individual and reflective manner. The surveys also included Likert-scale questions to measure their perceptions of teaching training and teaching activities, as well as potential barriers and facilitators. This mixed-methods approach enabled a comprehensive understanding of stakeholder perspectives across the cohorts. We designed focus groups and survey questions using the Theoretical Domains Framework (TDF) to provide an evidence-based structure to examine the psychological, social, and environmental factors influencing GP registrars' engagement in teaching ( 27 ). The recordings from the focus groups were transcribed using the Zoom auto- transcribe function and then reviewed for accuracy against the recording. The transcripts were analysed using NVivo software (version 14.23.3). Preliminary observations and reflections were noted during and after the sessions ( 28 ). Prior to the study, and on two further occasions, a stakeholder group was convened, comprising members involved in GP registrar and medical student education and representing the RACGP, the University of Melbourne, and the General Practice Student Network. The group included a medical student, a GP registrar, and a GP supervisor, and met regularly to ensure a robust study design and to consider the relevance and sustainability of the intervention. Recruitment GP registrars, GP supervisors, and medical students were recruited using a matched list of practices affiliated with the University of Melbourne and a list of Victorian registrars supplied by the RACGP. We also accessed our own professional networks and GP registrar and medical student social media groups. Registrars who expressed interest were contacted directly by the research team to minimise potential power dynamic issues or perceived pressure to participate between GP registrars and their supervisors/employers. The participant’s time for focus groups, completion of surveys and teacher training was compensated in the form of an electronic gift card consistent with research incentives recommended by VicREN , a practice-based research network managed by the University of Melbourne ( 29 ). Teaching sessions were not renumerated by the study, as practices that host students are remunerated via a Practice Incentive Payment (PIP) by the Australian government ( 30 ). Study Design The study was conducted in two phases: Phase 1: Co-Design and Piloting Co-Design Workshops were held to develop the teacher training, teaching activities and gain context for the overall study. Separate focus groups were held online for GP registrars (n = 8), GP supervisors (n = 5), and medical students (n = 7). Teacher Training : Registrars participated in two 2-hour online training sessions, covering adult learning theory and clinical teaching strategies. Teaching Activities : Registrars applied their training by organising and delivering teaching sessions to medical students within their clinics. Evaluation : Feedback was gathered through a GP registrar focus group (debrief workshop) and surveys of GP supervisors and medical students. Phase 2: Broader Implementation Intervention Roll-Out : A refined teaching model was implemented based on feedback from Phase 1 and involved 18 GP registrars. Data Collection : Pre-intervention surveys of GP registrars provided baseline data. Post-intervention surveys of registrars, GP supervisors and medical students were used to evaluate the impact of the intervention. Data Analysis Reflexive thematic analysis with a constructivist approach was utilised following the six steps drawn from Braun & Clarke (2021) ( 31 ). We used data from the codesign workshops, focus groups, teacher training sessions and the authors’ own personal notes. The researcher (HL) is a general practice owner, GP supervisor and lecturer at the University of Melbourne. He reflected on his own journey as a previous medical student and GP registrar and utilised his lens as a medical educator and clinician in the analysis of the qualitative data. He was guided by CJ, an experienced GP with academic leadership positions in medical education. HL was also advised by DRD, an experienced qualitative researcher in health, with input from AW and RS, who are experienced GP educators and clinicians. HL reviewed the data multiple times and created codes from the data. Early codes were sense checked by AW and DRD. A mind map of the codes was used to construct themes. Descriptive analysis was employed for quantitative data from Likert scales used in the surveys. Results Theme 1: Educator evolution, identity, competence and confidence Although most of the GP registrars had prior teaching experience (Table 1), many had sidelined their educator roles when entering GP training due to the formalised environment of medical student allocation to the educator in the primary care setting. “GP work is quite independent compared to the hospital… [In the hospital] medical students are always just kind of… hanging there, part of the team, and then there might be teaching… It’s quite informal. Whereas GP is quite independent, even when you're a registrar. And so, it's not as like, routine, to just have another person in the room with you . ” GP registrar 6- focus Group, phase 1 Supervisors highlighted the variability between clinics in allowing registrars to teach, emphasising that supporting registrars to continue teaching during their GP training could positively impact a sustainable teaching workforce. “When I was a registrar, I did have the opportunity to do a bit of teaching... there are a lot of registrars who really enjoy teaching... up to the point when they’re going to GP (training) and then all of a sudden, they’re not allowed to anymore… I think, you know, being able to support them, to doing that and continuing, that is going to make a difference for the long-term future of teaching in general practice” GP supervisor 3- focus group, phase 1 Some GP supervisors were unaware of the potential value of registrars as teaching resources. “(Interact 2) prompted us to review it (registrars teaching) as an option-we had not done this before, not because our registrars are not capable but because we had not thought of it!” GP Supervisor 3 - survey, phase 1 While practices, medical students and registrars were generally supportive of registrars taking on teaching roles, uncertainty about the preparedness of less experienced registrars (e.g. GPT1) sometimes created hesitation. “I reckon the transition to GPT1 is just so remarkable like it's so different to anything you ever do, prior, that to have a student in the room with me in GPT1 would have been just overwhelmingly difficult. It's only... in the later phase of reg training that I... would actually feel comfortable having to student in the room with me” GP registrar 7- focus group, phase 1 “I think the program is a great idea and hopefully can help normalise the idea of registrars as teachers. In my experience most registrars are suitable to participate as teachers once they are in their second year of GP training” GP Supervisor 2 - survey, phase 1 “So, with the registrars, who it was like their first year as a GP Registrar. They're very honest with me. They're like ‘oh, you know, like, we actually are still finding our feet. I don't really have the capacity to teach you, but you're welcome to sit in’. And so I played a much more passive role…” Medical student 3- focus group, phase 1 For most registrars, INTERACT 2’s provision of teacher training and scaffolding for creating their own teaching sessions was enriching and transformative. Teaching techniques employed by registrars in Phase 2 are recorded in Table 2. Registrars generally reported an increase in their readiness, confidence and interest in teaching as a result of participation in the project (Table 3). Registrars reported a shifting perspective about teaching, enhancing their skill set and contributing to their emerging competence as educators. “ I'd honestly never thought about teaching medical students before doing this. It was never something that was on my radar. But now I feel like it's something that I could do and incorporate into like my day.” GP registrar 8- focus group, phase 1 Registrars were asked about their interest in incorporating teaching into their future careers as GPs before and after the intervention. The results show that most registrars were already interested in teaching before the intervention and this interest was sustained post-intervention (Table 3). Theme 2: Work integration: Trade-offs of clinical and educator roles in an uncharted environment Although most registrars valued gaining teaching skills and experience, there was a nuanced perspective on their role as teachers. Many highlighted the tension between their own learning priorities and the professional obligation to teach. After the study, the perspectives shifted—some became more convinced of the importance of teaching, whereas a minority viewed it as a lesser priority than their own learning. “I think teaching is not really an important role for a GP registrar. But it wouldn't be a bad idea for a GP registrar to be involved in a bit of teaching because I think all doctors have some degree of obligation to contribute to the education of future generations of doctors. I think GP registrars should primarily focus on their own learning however, and [should] not take on too much teacher roles.” GP registrar 11- survey, phase 2 Teaching placed significant time and cognitive demands on GP registrars, often competing with their clinical responsibilities and personal learning needs. Registrars expressed the need for longer appointments or protected teaching time to feel more confident and reduce the strain of balancing teaching with other duties. Despite these difficulties, some registrars expressed a willingness to improve their time management to better integrate teaching into their roles. “It is already hard enough for GP registrars to have enough time and cognitive bandwidth to reflect adequately on each of their own individual cases without any teaching duties. For me, I foresee this being a major barrier. During this trial, I only had one half day with a student and my books were fortunately quite loosely booked, with FTAs (Failure to Attend), so my clinical duties were not adversely affected, but if I taught medical students more frequently this might have been a responsibility I needed to juggle with my clinical care and own learning responsibilities.” GP registrar 11- survey, phase 2 “Sometimes it does take longer and [it is] a bit difficult to balance but hoping to become better at time management regardless with or without students.” GP registrar 18- survey, phase 2 A key incentive of the educator role for GP registrars was renumeration for teaching time. Historically, registrars' teaching contributions have been informal and ad hoc, with practices reporting variability in how they involve and compensate registrars for teaching (Table 3). Many registrars noted that teaching responsibilities led to reduced patient billing, impacting earnings. “If it [the teaching] is fitting into our 38-hour week, if you're trying to earn above the minimum salary, that means that you're losing money. Yeah, because, you know, you're not necessarily billing as many patients (as you normally would). Yep, there, there's a trade-off.” GP registrar 1- focus group, phase 1 Practices adopted different policies for the distribution of the Practice Incentive Payments (PIPs). The study did not provide specific guidance on remuneration, however, some registrars reported instances of successful negotiation for monetary compensation for time spent teaching. “[We] will be distributing [the PIP] per %/ Dr including (GP) registrars who teach.” GP Supervisor 5- survey, phase 2 “The PIP is given mostly to the allocated doctor for the session. We don't allocate the [PIP to the] registrar…If we had a registrar who is more experienced and comfortable, I would ask them if they want to be allocated for the session.” GP Supervisor 6- survey, phase 2 Several registrars were unfamiliar with the details of the PIP for teaching medical students, creating uncertainty and discomfort about discussing renumeration. The complexities of defining a “teaching session” underscored broader challenges in integrating teaching into clinical workflows. Registrars expressed the need for clearer structures to ensure both effective teaching and equitable compensation. “They didn't bring it up and I was a bit too scared too. I also only did a few hours so was happy not to bring it up this time, but if I was to teach again, I would have to bring it up.” GP registrar 2- survey, phase 2 “it's a bit of a slap in the face. I feel like if the clinic passes on part of the PIP to the fellowed (qualified) GP but not the registrars, because I feel like you should be valued on the same level if you're providing it the same teaching service, and I think, renumerating us the same as they renumerate the other GPs is part of that.” GP registrar 8- focus group, phase 1 Theme 3. Stakeholder Collaboration: Impact of the project and scalability. GP registrars require the completion of a minimum number of clinical contact hours as part of their training program. Some registrars expressed concern that teaching would not count toward these requirements, potentially impacting training progression. The project team clarified this with the RACGP Victorian Censor to determine the maximum teaching allowances for GP registrars according to their training level, thus removing any perceived barrier to training progression. The maximum allowable time is up to 3 hours per week for registrars in GP Term 3 or Extended Skills, 2 hours per week in GP Term 2, and 1 hour per week in GP Term 1. For part-time registrars, this allocation is prorated according to hours worked. These hours may be distributed flexibly across the term. For example, a registrar in GP Term 3 could complete the full 60-hour allocation at an accelerated pace during the placement. In Phase 1, all the learners were medical students. When testing the approach at scale in Phase 2, the researchers allowed the GP registrars to teach allied health colleagues or fellow registrars. This was intentional, given that the objective was to expose GP registrars to teaching opportunities and build capacity within general practice. Notwithstanding the small number of non-medical students, we explored the influence of the project on medical students’ learning, engagement, and interest in pursuing general practice as a career. Among the 12 recipients of GP registrar teaching who completed the post-intervention survey in Phase 2, only one had prior experience of being taught by a GP registrar. Despite this, all the participants reported positive or very positive experiences from the teaching activities delivered by registrars (Table 5). Notably, the project increased learners' support for GP registrars as educators with all students reporting it had a positive impact on their learning on GP placement. The project also enhanced the appeal of general practice as a career with 89% of students reporting an increase in the appeal of GP as a result of being taught by a GP registrar (Table 5). Medical students reflected on the relatability and enthusiasm that GP registrars brought to their teaching roles: “I thought speaking with someone that was more recently graduated was a big factor in increasing my interest in general practice as I felt they were more able to relate to what GP placement is like for students and were more able to highlight the interesting and helpful parts of GP for students.” Medical student 8- phase 2 survey The study had a significant impact on supervisors' perceptions of registrars as clinical educators by fostering conversations about readiness and providing a framework for teaching. Supervisors noted that the program empowered registrars to step into teaching roles and offered practical guidance for integrating students into their consultations. Additionally, supervisors began utilising registrars more effectively in teaching scenarios, such as when their own availability was limited, highlighting the program's role in enhancing workflow flexibility and collaboration. “Interact 2 [the program] improved my attitude to registrars as clinical educators. Prior to Interact 2, I believed registrars would be well equipped to teach students, however time pressures and not being sure if the registrar would be interested or willing were barriers to it actually occurring. Interact enabled conversations about willingness, confidence and logistics of a registrar teaching the students.” GP supervisor 5- survey, phase 1 GP supervisors consistently supported GP registrars as teachers both before and after the intervention, with most rating their support as “very” or “extremely” high. Post-intervention, all supervisors rated GP registrars as at least moderately ready to teach, with 88% selecting “very” or “extremely.” The INTERACT2 program was perceived to have a neutral or positive impact on time management, workflow, and stress levels, and it was seen as enhancing the learning environment, with all supervisors reporting a positive effect (Table 4). Registrars reported needing to take initiative with organisational tasks relevant to teaching such as negotiating time off during work hours and coordinating with practice managers. “I know for me like there was quite a bit of leg work I did have to do, even just to kind of get the time off to attend the teaching sessions [be]cause it was on my, you know, during my work hours and then following it up with the practice manager and that sort of thing... ” GP registrar 1- focus group, phase 1 The Response rates to the surveys are recorded in the appendix. Discussion The purpose of our study was to create a model that could be scaled state or nationwide and become a routine part of GP training. Our study is novel by demonstrating an approach that can improve teaching confidence, teaching participation and engagement in early career doctors. Furthermore, this study actively involved other crucial stakeholders, namely medical students and GP supervisors, underscoring the collaborative nature of the proposed model. With the right timing and availability of learners such as medical students our intervention can be scalable and equip GP registrars with teaching skills to foster the next generation of doctors. The study could also translate to faculty development in allied health professions who have community work-based learning such as physiotherapy, social work, occupational therapy, optometry, etc. The components of our model could also be applied in other countries where training of health professionals includes community settings. Our study supports the view that GP registrars can positively impact the learning environment in general practice when supported by a structured teacher training framework, dedicated teaching sessions, and support from practices and GP supervisors. During the study, we observed the emergence of a dual professional identity in GP registrars, blending their roles as educators and clinicians. This aligns with findings from other research ( 22 ), highlighting similar outcomes among GP registrars involved in multilevel teaching initiatives. The benefits, barriers and facilitators of multilevel learning and near-peer teaching for GP registrars are well studied ( 3 , 8 , 16 , 32 – 34 ). Similar findings such as improved teaching culture, medical student engagement, and workflow were congruent with published data. Barriers such as time, availability and scheduling of medical students were also confirmed ( 35 ). This study was unique in its co-design approach, which empowered registrars, enhanced confidence, and improved readiness to teach. Our iterative approach further refined the model, leading to shortened upfront teacher training and supplementary teaching materials summarising key techniques, ensuring a feasible and sustainable integration of teaching into GP registrar training. It has been established that GP registrar-led teaching sessions can empower motivated registrars to gain teaching experience while deepening their own learning ( 12 ). This study supports the notion that GP registrars are self-regulated learners ( 13 ) who, with adequate support, can take initiative in organising their teaching opportunities. However, this empowerment may come at a cost, as registrars might spend valuable training time coordinating and preparing for teaching sessions. Previous research highlights the numerous competing priorities already faced by GP registrars ( 34 , 36 ). In reality, this ‘time commitment’ can be mitigated by sharing or delegating this co-ordination role with the practice manager. A key strength of this project was its flexibility—neither the duration nor the format of the teaching activities were prescribed which provided the registrars with agency and control over their teaching role. GP registrars, medical students, and GP supervisors expressed some hesitation about recommending early registrars to teach medical students, citing the registrars' relative inexperience and the increased cognitive demands of transitioning to primary care, which is also consistent with other studies ( 32 , 36 , 37 ). This study included very few GPT1 participants, which may reflect a degree of self-exclusion by GPT1 registrars. However, this hesitancy must be balanced against the risk of sidelining valuable teaching experience, as highlighted in discussions with registrars who had prior teaching experience but reported neglecting it during their GP training. These dynamics align with Keegan’s stages of professional identity formation, where learners transition from dependent, rule-based novices to more autonomous, adaptive professionals ( 38 , 39 ). Early registrars may hesitate to teach due to a lack of confidence or identity as educators, but structured teaching roles could support their professional development by reinforcing their dual identity as both learners and teachers. Furthermore, times of discomfort can serve as accelerants for professional identity formation, as individuals are often forced to reevaluate and solidify their sense of self in challenging or uncertain conditions ( 40 ). Our study—along with the authors’ own experiences—highlighted that teaching can be an uncomfortable yet transformative experience, particularly for those early in their careers. This aligns with Bjork’s “Desirable Difficulties” framework, which posits that learning is more durable when it involves effortful engagement and challenge ( 41 ). These principles further align with Vygotsky's Zone of Proximal Development, which emphasises that learners develop most effectively when given tasks slightly beyond their current capabilities, provided they receive adequate scaffolding and support ( 42 ). Encouraging supervised teaching opportunities for early GP registrars could therefore serve as both a learning and identity-forming experience, reinforcing their development as confident and capable clinicians. There is a notable absence of structured teaching to equip registrars with teaching skills within the Australian GP registrar training program ( 16 ) and in countries with comparable training models, such as the UK ( 8 ). Given the clear benefits of near-peer teaching, we encourage professional bodies, supervisors, and practices to actively support and facilitate registrar-led teaching opportunities for medical students. Rather than a passive or ad-hoc approach, teaching should be recognised as a valuable component of registrar training and professional development, implemented flexibly based on individual readiness and institutional support. This study was the first to explore how practices generally distribute their teaching income and how registrars were allocated teaching payments when assigned formalized teaching sessions. We observed significant variability in how teaching payments were distributed to registrars. Previous research has highlighted the need for greater transparency in teaching-related funding allocation ( 35 ). This study found that both GP supervisors and GP registrars generally agreed that registrars should be remunerated for their teaching time. However, how to best align this with current collective employment contracts warrants further attention. Previous studies reported that some GP registrars thought that teaching would occur outside of training time ( 36 ). As part of our stakeholder engagement, we were able to gain clarification from the RACGP Victorian Censor that training time could be counted towards training which can further incentivise GP registrars to teach. This study aligns with existing literature suggesting that, despite challenges, near-peer teaching offers significant benefits ( 16 , 34 ). Our findings revealed that medical students responded very positively to the experience and expressed increased interest in pursuing general practice as a career ( 35 ). Feedback from GP supervisors was also favourable, with most reporting neutral or positive effects on their workflow and stress levels. From a policy point of view, the number of the medical students are expanding and the need for greater number of general practitioners is also high on the agenda for many countries ( 43 )( 44 ). Clinical training places for medical students in general practice has been identified as a solution to the training shortfall ( 21 ). There is also recognition of community-based learning experiences being of high relevancy to the foundations of patient care and relevant to the health needs of our population ( 33 ). Furthermore, there is a shortage of GP educator workforce ( 11 , 32 ). GP registrars may be an untapped resource which can fill the gap in educators of medical students and further encourage students to choose general practice as a career pathway. Multi-level learning involving registrars and medical students will require input from relevant training organisations and universities. A teaching training session could therefore be collaboratively provided by the GP training programs and medical schools ( 6 , 16 , 21 , 23 ). Explicit guidance informed by our model could help facilitate near-peer teaching sessions and provide essential support for registrars in their teaching roles. This study had some limitations. We were not able to delineate a direct correlation between our model and improved readiness to teach, but we can deduce from other literature ( 34 , 45 ) that the provision of training followed by an opportunity to teach are likely contributing factors. The response rate to the phase 2 survey of GP supervisors of 44% was lower than the 83% response rate in the smaller phase 1 cohort. We hypothesise that this decline was due to lower engagement, as the phase 2 GP registrars were not involved in co-design and our distribution of surveys was predominantly driven by registrars. As mentioned, our study tended to have more experienced registrars from metropolitan areas and may not be transferrable to early GP registrars and other geographical locations. This study demonstrates that with appropriate training, support, and institutional awareness, GP registrars can confidently take the helm as educators within a multi-level learning framework. By charting a co-designed approach the study enhanced registrars' confidence and readiness to teach, contributing to their professional development and enriching medical education in general practice. The findings reinforce the mutual benefits of near-peer teaching for GP registrars, medical students and GP supervisors while also highlighting the need for structured teaching programs, clearer funding policies and stronger institutional supports to facilitate GP registrars as educators in the clinical setting. Abbreviations AGPT Australian General Practice Training Program FTAs Failure to Attend GP General practitioner GPT1 General practice term 1 INTERACT Integrating Registrars As Clinical Teachers (Project) PIP Practice incentive payment RACGP Royal Australian College of General Practitioners VicREN Victorian Primary Care Practice-based Research and Education Network Declarations The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Ethics and Consent to Participate Ethics approval for this project was granted by the Human Ethics Team at the University of Melbourne. Reference Number:2024-29154-53087-2. All participants received written information about the study and provided informed consent prior to participation. The authors conducted the study in accordance with the ethical principles outlined in the Declaration of Helsinki. Consent for publication Not applicable. Availability of Data and Materials The data sets generated from this study are not publicly available due to ethical and privacy restrictions but are available from the corresponding author on reasonable request. Competing Interests All authors have completed the ICMJE uniform disclosure form and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Funding This research project is supported by the Royal Australian College of General Practitioners (RACGP) through the 2023 Education Research grant ERG2024-08 and by the Richard Gilmour-Smith Research Trust grant 051633. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. Authors’ Contributions The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. HL wrote the manuscript, conducted the qualitative analysis, generated initial codes, and developed themes. CJ conceived the study and helped develop the analytical framework. DRD prepared Tables 1–5 and helped analyse the data. Early codes were sense-checked by AW and DRD. RS helped analyse the quantitative data. All authors contributed to the study’s conceptual development, provided methodological or analytical input, edited the manuscript, and approved the final version. Acknowledgments We extend our sincere gratitude to the following individuals for their invaluable contributions as stakeholders in this study: Dr. Niroshe Amarasekera, Dr. Katie Fisher, Jane Henty, Dr. Stephanie Parker, Dr. Morgan Raynor, Dr. Angelina Salamone, Dr. Wonie Uahwatanasakul, Dr. Ed Vergara, Bianca Vardanega, and Jasmine Yip. We also extend our appreciation to all study participants, whose valuable time and contributions provided critical insights into the experiences and realities of GP registrars engaged in teaching. The participants and stakeholders were instrumental in shaping the co-design and implementation of this project. Their perspectives enriched our understanding of the challenges and facilitators in integrating teaching into GP training, ensuring that our findings are both relevant and applicable to real-world educational practice. Provenance and peer review Not commissioned; externally peer reviewed. References Australia Government DoH, Care A. GP Supply and Demand Study Compendium - August 2024 2024 [Available from: https://hwd.health.gov.au/resources/primary/gp-supply-and-demand-study-compendium-august-2024.pdf. Landstrom B, Mattsson B, Nordin P, Rudebeck CE. The characteristics of general practice and the attractiveness of working as a GP: medical students views. 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An evaluation of the views of GP Specialty Trainees on their involvement in medical student teaching. Educ Prim Care. 2018;29(2):100–3. Alberti H, Carlin E, Harrison M. What factors influence intention towards a career in general practice? Br J Gen Pract. 2017;67(659):253. Banner K, Alberti H, Khan SA, Jones MM, Pope LM. ‘They say’: Medical students’ perceptions of general practice, experiences informing these perceptions, and their impact on career intention – A qualitative study among medical students in England. BMJ Open. 2023;13(11):e073429. Thomson JS, Anderson KJ, Mara PR, Stevenson AD. Supervision—growing and building a sustainable general practice supervisor system. Medical Journal of Australia. 2011;194(11):S101. Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education. Med Teach. 2007;29(6):546-52. Royal Australian College of General Practitioners. 2022 RACGP curriculum and syllabus for Australian general practice 2022 [Available from: https://www.racgp.org.au/education/gp-training/gps-in-training/academic-posts. The College of Family Physicians of Canada. Standards of Accreditation for Residency Programs in Family Medicine. 2 ed. Mississauga, ON2020. Royal Australian College of General Practitioners. AGPT Academic Post Program 2025 [Available from: https://www.racgp.org.au/education/gp-training/gps-in-training/academic-posts. Fisher K, Patsan I, Klein L, Turner A, Runciman D, Fielding A, et al. Registrars as teachers: a qualitative study exploring the experiences of Australian general practice registrars in teaching roles. BMC Medical Education. 2024;24(1):1203. PMCV. Teaching on the Run Program (TOTR) 2024 [Available from: https://www.pmcv.com.au/education-training/teaching-on-the-run/. University of Melbourne. 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Johnson C LS, McNair R, Poliness E, Trumble S, Tse J. INTERACT: Integrating Registrars As Clinical Teachers - Pilot Study. Final Report. Department of General Practice, University of Melbourne; 2003. Meyer J. Using qualitative methods in health related action research. Bmj. 2000;320(7228):178-81. Cameron C. The evolution of a mixed methods study in work-integrated learning. International Journal of Work-Integrated Learning. 2018;19(3):237-47. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science. 2017;12(1). Maher C, Hadfield M, Hutchings M, De Eyto A. Ensuring rigor in qualitative data analysis: A design research approach to coding combining NVivo with traditional material methods. International journal of qualitative methods. 2018;17(1):1609406918786362. Department of General Practice and Primary Care UoM. VICREN – Victorian Primary Care Research and Education Network: The University of Melbourne; 2024 [Available from: https://medicine.unimelb.edu.au/school-structure/general-practice-and-primary-care/engagement/primary-care-community/research/vicren. Australia S. Practice Incentives Program Teaching Payment Guidelines Effective 1 August 2024 2024 [Available from: https://www.servicesaustralia.gov.au/sites/default/files/2024-08/teaching-payment-pip-guidelines-2.docx. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology. 2021;18(3):328-52. Dick MLB, King DB, Mitchell GK, Kelly GD, Buckley JF, Garside SJ. Vertical integration in teaching and learning (VITAL): an approach to medical education in general practice. Medical Journal of Australia. 2007;187(2):133-5. Dick ML, Henderson M, Wei Y, King D, Anderson K, Thistlethwaite J. A systematic review of the approaches to multi-level learning in the general practice context, using a realist synthesis approach: BEME Guide No. 55. Medical Teacher. 2019;41(8):862-76. Bull S, Coster S, Scott K, Forrest D, Parkeh R, Horsburgh J. GP trainees as teachers: a rapid review of the barriers, facilitators and outcomes. Educ Prim Care. 2024;35(1–2):30–45. Thomson JS, Anderson K, Haesler E, Barnard A, Glasgow N. The learner’s perspective in GP teaching practices with multi-level learners: a qualitative study. BMC medical education. 2014;14:1-10. Harrison M, Alberti H, Thampy H. Barriers to involving GP speciality trainees in the teaching of medical students in primary care: the GP trainer perspective. Education for Primary Care. 2019;30(6):347-54. Silberberg P, Ahern C, van de Mortel TF. ‘Learners as teachers’ in general practice: stakeholders’ views of the benefits and issues. Education for Primary Care. 2013;24(6):410-7. Kegan R. In Over Our Heads: The Mental Demands of Modern Life. Harvard University Press1994. Lewin LO, McManamon A, Stein MTO, Chen DT. Minding the form that transforms: using Kegan's model of adult development to understand personal and professional identity formation in medicine. Acad Med. 2019;94(9):1299-304. Brown ME, Lim JH, Horsburgh J, Pistoll C, Thakerar V, Maini A, et al. Identity development in disorientating times: the experiences of medical students during COVID-19. Medical Science Educator. 2022;32(5):995-1004. Bjork RA, Bjork EL. Desirable difficulties in theory and practice. Journal of Applied research in Memory and Cognition. 2020;9(4):475. Vygotsky L. Mind in Society: The Development of Higher Psychological Processes. Harvard University Press1978. Zealand MDAaN. Position Paper: The Doctors our Communities Need: Building, Sustaining and Supporting the General Practice Workforce in Australia and New Zealand. Sydney, Australia 2023 [Available from: efaidnbmnnnibpcajpcglclefindmkaj/https://medicaldeans.org.au/md/2023/10/The-Doctors-our-comminity-needs-Medical-Deans-Position-Paper-2023.pdf. (UK) MSC. The expansion of medical student numbers [13/05/2025]. Available from: https://www.medschools.ac.uk/our-work/the-expansion-of-medical-student-numbers. Usherwood T, Mishra A, Knight A. Registrars are teachers too! Medical Education. 2004;38(11):1189-90. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files MedicalStudentSurveyINTERACT2Phase1.pdf MedicalStudentSurveyINTERACT2Phase2.pdf GPSupervisorSurveyINTERACT2Phase1.pdf GPSupervisorSurveyINTERACT2Phase2.pdf GPRegistrarINTERACT2Phase2PostInterventionsurvey.pdf Tables.docx Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 23 Oct, 2025 Editor invited by journal 30 Sep, 2025 Submission checks completed at journal 30 Sep, 2025 First submitted to journal 27 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Their involvement in the primary care teaching workforce has shown a favourable impact on engagement and perception among medical students regarding general practice. However, it is noteworthy that when GP registrars undertake teaching responsibilities, it is frequently conducted in an informal and ad hoc manner, lacking structured frameworks or formalised processes, and thus GP registrars are seldom utilised or incentivised to be a core part of the primary care educational faculty.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e \u0026ndash; The provision of brief formalised teacher training sessions and supported teaching activities can develop confidence, competence and identity as an educator for GP registrars. Registrars can formally play a greater role in medical student or other near-peer teaching during their training. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHow this study might affect research, practice or policy\u003c/strong\u003e \u0026ndash; The learnings and structure of this co-designed intervention could be scaled more broadly. A structured teaching program, clearer funding policies and stronger institutional supports can facilitate and promote GP registrars as educators in the primary care clinical setting. This project provides a transferable framework for a broader roll out and could be integrated into current GP training in a variety of contexts, providing benefits such as an improved GP registrar professional development, a diverse educational faculty for the profession and better engagement of medical students in general practice.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe training of general practitioners (GPs) remains critical to ensuring a sustainable and effective healthcare system(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The role of GPs as educators of this workforce can enhance learning experiences for medical students and strengthen general practice as a career choice (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Universities have expanded student placements in primary care to address GP workforce shortages (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, high-quality placements are necessary to encourage greater numbers of medical students to enter general practice (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTraditionally, medical student education in the general practice setting is conducted by qualified GPs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). GP registrars, also known as GP trainees or general practice residents are known to play informal roles in the training of medical students in the clinical setting (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This concept is known under the umbrella of \u0026lsquo;near-peer teaching\u0026rsquo; where a learner teaches another learner at a more junior or similar stage of training (e.g. GP registrars teaching medical students). Near-peer teaching has been found to improve medical students\u0026rsquo; perception of general practice as a career choice (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Near-peer teaching operates within the broader framework of multi-level learning (or vertical integration of learning), which incorporates different levels of learners, including medical students, GP registrars, and supervisors. The adoption of multi-level learning strategies can also benefit GP registrars, by providing an improved understanding of clinical knowledge, and opportunities for professional development (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and supervisors, by having a shared teaching load (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and improved workflow (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGP professional colleges in countries including Australia, UK and Canada GP curriculum recognise that teaching is a core competency for all GPs (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, strategies to develop teaching competencies in GP registrars during vocational training are limited (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Although teacher training courses are available (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), these come at significant costs, posing a barrier for early career GPs, who are already facing other significant financial and time pressures (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere are a relatively small number of opportunities within GP specialty training programs to gain formal teaching skills (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). For example, the AGPT (Australian General Practice Training Program) Academic Post Program has 20 positions for GP registrars nationwide (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). From a pool of 39,449 registrars (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Most teaching opportunities for GP registrars are therefore circumstantial, unplanned, and unsupported, often sidelining registrars who may otherwise embrace teaching as part of their professional identity (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur goal was to co-design a model with GP registrars that could help them develop teaching skills, while positively impacting the learning environment within general practice. Co-design was used to ensure that the model was relevant and practical for GP registrars, while encouraging key stakeholder engagement. A secondary aim of the study was to explore how near-peer teaching could expand our teaching workforce and provide insights into the process of training doctors to become clinical educators. Thirdly, we aimed to create a model for supporting near-peer teaching that was scalable at a state or national level in Australia.\u003c/p\u003e\u003cp\u003eThis study builds on the learning of the Integrating Registrars As Clinical Teachers (INTERACT) project in 2003, which provided teacher training to a small number of highly committed GP registrars who wanted to teach medical students (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe used a sequential mixed method research design with two phases. The iterative approach was designed to address practical challenges in GP education and empower participants through a participatory approach (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In both phases we collected qualitative and quantitative data, with the qualitative component being more prominent. In this study, \u0026lsquo;GP registrar\u0026rsquo; refers to participants enrolled in the RACGP AGPT program.\u003c/p\u003e\u003cp\u003e Separate focus groups were conducted for each participant group, ensuring that participants could share insights freely within their peer group. Open-ended questions encouraged rich, detailed responses to allow us to construct deep themes.\u003c/p\u003e\u003cp\u003eOpen-ended questions were also included in surveys administered through \u003cem\u003eQualtrics\u003c/em\u003e for each stakeholder group, allowing participants to elaborate on their views and experiences in a more individual and reflective manner. The surveys also included Likert-scale questions to measure their perceptions of teaching training and teaching activities, as well as potential barriers and facilitators. This mixed-methods approach enabled a comprehensive understanding of stakeholder perspectives across the cohorts. We designed focus groups and survey questions using the Theoretical Domains Framework (TDF) to provide an evidence-based structure to examine the psychological, social, and environmental factors influencing GP registrars' engagement in teaching (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe recordings from the focus groups were transcribed using the \u003cem\u003eZoom\u003c/em\u003e auto- transcribe function and then reviewed for accuracy against the recording. The transcripts were analysed using \u003cem\u003eNVivo\u003c/em\u003e software (version 14.23.3). Preliminary observations and reflections were noted during and after the sessions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrior to the study, and on two further occasions, a stakeholder group was convened, comprising members involved in GP registrar and medical student education and representing the RACGP, the University of Melbourne, and the General Practice Student Network. The group included a medical student, a GP registrar, and a GP supervisor, and met regularly to ensure a robust study design and to consider the relevance and sustainability of the intervention.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment\u003c/h2\u003e\u003cp\u003eGP registrars, GP supervisors, and medical students were recruited using a matched list of practices affiliated with the University of Melbourne and a list of Victorian registrars supplied by the RACGP. We also accessed our own professional networks and GP registrar and medical student social media groups. Registrars who expressed interest were contacted directly by the research team to minimise potential power dynamic issues or perceived pressure to participate between GP registrars and their supervisors/employers. The participant\u0026rsquo;s time for focus groups, completion of surveys and teacher training was compensated in the form of an electronic gift card consistent with research incentives recommended by \u003cem\u003eVicREN\u003c/em\u003e, a practice-based research network managed by the University of Melbourne (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Teaching sessions were not renumerated by the study, as practices that host students are remunerated via a Practice Incentive Payment (PIP) by the Australian government (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in two phases:\u003c/p\u003e\n\u003ch3\u003ePhase 1: Co-Design and Piloting\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCo-Design Workshops\u003c/b\u003e were held to develop the teacher training, teaching activities and gain context for the overall study. Separate focus groups were held online for GP registrars (n\u0026thinsp;=\u0026thinsp;8), GP supervisors (n\u0026thinsp;=\u0026thinsp;5), and medical students (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTeacher Training\u003c/b\u003e: Registrars participated in two 2-hour online training sessions, covering adult learning theory and clinical teaching strategies.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTeaching Activities\u003c/b\u003e: Registrars applied their training by organising and delivering teaching sessions to medical students within their clinics.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEvaluation\u003c/b\u003e: Feedback was gathered through a GP registrar focus group (debrief workshop) and surveys of GP supervisors and medical students.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003ePhase 2: Broader Implementation\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIntervention Roll-Out\u003c/b\u003e: A refined teaching model was implemented based on feedback from Phase 1 and involved 18 GP registrars.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e: Pre-intervention surveys of GP registrars provided baseline data. Post-intervention surveys of registrars, GP supervisors and medical students were used to evaluate the impact of the intervention.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eReflexive thematic analysis with a constructivist approach was utilised following the six steps drawn from Braun \u0026amp; Clarke (2021) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). We used data from the codesign workshops, focus groups, teacher training sessions and the authors\u0026rsquo; own personal notes. The researcher (HL) is a general practice owner, GP supervisor and lecturer at the University of Melbourne. He reflected on his own journey as a previous medical student and GP registrar and utilised his lens as a medical educator and clinician in the analysis of the qualitative data. He was guided by CJ, an experienced GP with academic leadership positions in medical education. HL was also advised by DRD, an experienced qualitative researcher in health, with input from AW and RS, who are experienced GP educators and clinicians. HL reviewed the data multiple times and created codes from the data. Early codes were sense checked by AW and DRD. A mind map of the codes was used to construct themes.\u003c/p\u003e\u003cp\u003eDescriptive analysis was employed for quantitative data from Likert scales used in the surveys.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Educator evolution, identity, competence and confidence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough most of the GP registrars had prior teaching experience (Table 1), many had sidelined their educator roles when entering GP training due to the formalised environment of medical student allocation to the educator in the primary care setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“GP work is quite independent compared to the hospital… [In the hospital] medical students are always just kind of… hanging there, part of the team, and then there might be teaching… It’s quite informal. Whereas GP is quite independent, even when you're a registrar. And so, it's not as like, routine, to just have another person in the room with you\u003cstrong\u003e.\u003c/strong\u003e”\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;GP registrar 6- focus Group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupervisors highlighted the variability between clinics in allowing registrars to teach, emphasising that supporting registrars to continue teaching during their GP training could positively impact a sustainable teaching workforce.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When I was a registrar, I did have the opportunity to do a bit of teaching... there are a lot of registrars who really enjoy teaching... up to the point when they’re going to GP (training) and then all of a sudden, they’re not allowed to anymore… I think, you know, being able to support them, to doing that and continuing, that is going to make a difference for the long-term future of teaching in general practice”\u003c/em\u003e \u003cstrong\u003eGP supervisor 3- focus group, phase 1\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome GP supervisors were unaware of the potential value of registrars as teaching resources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“(Interact 2) prompted us to review it (registrars teaching) as an option-we had not done this before, not because our registrars are not capable but because we had not thought of it!”\u003c/em\u003e \u003cstrong\u003eGP Supervisor 3 - survey, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile practices, medical students and registrars were generally supportive of registrars taking on teaching roles, uncertainty about the preparedness of less experienced registrars (e.g. GPT1) sometimes created hesitation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I reckon the transition to GPT1 is just so remarkable like it's so different to anything you ever do, prior, that to have a student in the room with me in GPT1 would have been just overwhelmingly difficult. It's only... in the later phase of reg training that I... would actually feel comfortable having to student in the room with me”\u003c/em\u003e \u003cstrong\u003eGP registrar 7- focus group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think the program is a great idea and hopefully can help normalise the idea of registrars as teachers. In my experience most registrars are suitable to participate as teachers once they are in their second year of GP training”\u003c/em\u003e \u003cstrong\u003eGP Supervisor 2 - survey, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So, with the registrars, who it was like their first year as a GP Registrar. They're very honest with me. They're like ‘oh, you know, like, we actually are still finding our feet. I don't really have the capacity to teach you, but you're welcome to sit in’. And so I played a much more passive role…”\u003c/em\u003e \u003cstrong\u003eMedical student 3- focus group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor most registrars, INTERACT 2’s provision of teacher training and scaffolding for creating their own teaching sessions was enriching and transformative. Teaching techniques employed by registrars in Phase 2 are recorded in Table 2. Registrars generally reported an increase in their readiness, confidence and interest in teaching as a result of participation in the project (Table 3). Registrars reported a shifting perspective about teaching, enhancing their skill set and contributing to their emerging competence as educators.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“\u003c/em\u003e\u003cem\u003eI'd honestly never thought about teaching medical students before doing this. It was never something that was on my radar. But now I feel like it's something that I could do and incorporate into like my day.”\u003c/em\u003e \u003cstrong\u003eGP registrar 8- focus group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegistrars were asked about their interest in incorporating teaching into their future careers as GPs before and after the intervention. The results show that most registrars were already interested in teaching before the intervention and this interest was sustained post-intervention (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Work integration: Trade-offs of clinical and educator roles in an uncharted environment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough most registrars valued gaining teaching skills and experience, there was a nuanced perspective on their role as teachers. Many highlighted the tension between their own learning priorities and the professional obligation to teach. After the study, the perspectives shifted—some became more convinced of the importance of teaching, whereas a minority viewed it as a lesser priority than their own learning.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think teaching is not really an important role for a GP registrar. But it wouldn't be a bad idea for a GP registrar to be involved in a bit of teaching because I think all doctors have some degree of obligation to contribute to the education of future generations of doctors. I think GP registrars should primarily focus on their own learning however, and [should] not take on too much teacher roles.”\u003c/em\u003e \u003cstrong\u003eGP registrar 11- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeaching placed significant time and cognitive demands on GP registrars, often competing with their clinical responsibilities and personal learning needs. Registrars expressed the need for longer appointments or protected teaching time to feel more confident and reduce the strain of balancing teaching with other duties. \u0026nbsp;Despite these difficulties, some registrars expressed a willingness to improve their time management to better integrate teaching into their roles.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It is already hard enough for GP registrars to have enough time and cognitive bandwidth to reflect adequately on each of their own individual cases without any teaching duties. For me, I foresee this being a major barrier. During this trial, I only had one half day with a student and my books were fortunately quite loosely booked, with FTAs (Failure to Attend), so my clinical duties were not adversely affected, but if I taught medical students more frequently this might have been a responsibility I needed to juggle with my clinical care and own learning responsibilities.”\u003c/em\u003e \u003cstrong\u003eGP registrar 11- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Sometimes it does take longer and [it is] a bit difficult to balance but hoping to become better at time management regardless with or without students.”\u003c/em\u003e \u003cstrong\u003eGP registrar 18- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key incentive of the educator role for GP registrars was renumeration for teaching time. Historically, registrars' teaching contributions have been informal and ad hoc, with practices reporting variability in how they involve and compensate registrars for teaching (Table 3). Many registrars noted that teaching responsibilities led to reduced patient billing, impacting earnings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If it [the teaching] is fitting into our 38-hour week, if you're trying to earn above the minimum salary, that means that you're losing money. Yeah, because, you know, you're not necessarily billing as many patients (as you normally would). Yep, there, there's a trade-off.”\u003c/em\u003e \u003cstrong\u003eGP registrar 1- focus group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePractices adopted different policies for the distribution of the Practice Incentive Payments (PIPs). The study did not provide specific guidance on remuneration, however, some registrars reported instances of successful negotiation for monetary compensation for time spent teaching.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[We] will be distributing [the PIP] per %/ Dr including (GP) registrars who teach.”\u003c/em\u003e \u003cstrong\u003eGP Supervisor 5- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The PIP is given mostly to the allocated doctor for the session. We don't allocate the [PIP to the] registrar…If we had a registrar who is more experienced and comfortable, I would ask them if they want to be allocated for the session.”\u003c/em\u003e \u003cstrong\u003eGP Supervisor 6- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral registrars were unfamiliar with the details of the PIP for teaching medical students, creating uncertainty and discomfort about discussing renumeration. The complexities of defining a “teaching session” underscored broader challenges in integrating teaching into clinical workflows. Registrars expressed the need for clearer structures to ensure both effective teaching and equitable compensation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They didn't bring it up and I was a bit too scared too. I also only did a few hours so was happy not to bring it up this time, but if I was to teach again, I would have to bring it up.”\u003c/em\u003e \u003cstrong\u003eGP registrar 2- survey, phase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“it's a bit of a slap in the face. I feel like if the clinic passes on part of the PIP to the fellowed (qualified) GP but not the registrars, because I feel like you should be valued on the same level if you're providing it the same teaching service, and I think, renumerating us the same as they renumerate the other GPs is part of that.”\u003c/em\u003e \u003cstrong\u003eGP registrar 8- focus group, phase 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3. Stakeholder Collaboration: Impact of the project and scalability.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGP registrars require the completion of a minimum number of clinical contact hours as part of their training program. \u0026nbsp;Some registrars expressed concern that teaching would not count toward these requirements, potentially impacting training progression. The project team clarified this with the RACGP Victorian Censor to determine the maximum teaching allowances for GP registrars according to their training level, thus removing any perceived barrier to training progression. The maximum allowable time is up to 3 hours per week for registrars in GP Term 3 or Extended Skills, 2 hours per week in GP Term 2, and 1 hour per week in GP Term 1. For part-time registrars, this allocation is prorated according to hours worked. These hours may be distributed flexibly across the term. For example, a registrar in GP Term 3 could complete the full 60-hour allocation at an accelerated pace during the placement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Phase 1, all the learners were medical students. When testing the approach at scale in Phase 2, the researchers allowed the GP registrars to teach allied health colleagues or fellow registrars. This was intentional, given that the objective was to expose GP registrars to teaching opportunities and build capacity within general practice. Notwithstanding the small number of non-medical students, we explored the influence of the project on medical students’ learning, engagement, and interest in pursuing general practice as a career.\u003c/p\u003e\n\u003cp\u003eAmong the 12 recipients of GP registrar teaching who completed the post-intervention survey in Phase 2, only one had prior experience of being taught by a GP registrar. Despite this, all the participants reported positive or very positive experiences from the teaching activities delivered by registrars (Table 5). Notably, the project increased learners' support for GP registrars as educators with all students reporting it had a positive impact on their learning on GP placement. The project also enhanced the appeal of general practice as a career with 89% of students reporting an increase in the appeal of GP as a result of being taught by a GP registrar (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedical students reflected on the relatability and enthusiasm that GP registrars brought to their teaching roles:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I thought speaking with someone that was more recently graduated was a big factor in increasing my interest in general practice as I felt they were more able to relate to what GP placement is like for students and were more able to highlight the interesting and helpful parts of GP for students.”\u003c/em\u003e \u003cstrong\u003eMedical student 8- phase 2 survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe study\u0026nbsp;\u003c/strong\u003ehad a significant impact on supervisors' perceptions of registrars as clinical educators by fostering conversations about readiness and providing a framework for teaching. Supervisors noted that the program empowered registrars to step into teaching roles and offered practical guidance for integrating students into their consultations. Additionally, supervisors began utilising registrars more effectively in teaching scenarios, such as when their own availability was limited, highlighting the program's role in enhancing workflow flexibility and collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Interact 2 [the program] improved my attitude to registrars as clinical educators. Prior to Interact 2, I believed registrars would be well equipped to teach students, however time pressures and not being sure if the registrar would be interested or willing were barriers to it actually occurring. Interact enabled conversations about willingness, confidence and logistics of a registrar teaching the students.”\u003c/em\u003e \u003cstrong\u003eGP supervisor 5- survey, phase 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGP supervisors consistently supported GP registrars as teachers both before and after the intervention, with most rating their support as “very” or “extremely” high. Post-intervention, all supervisors rated GP registrars as at least moderately ready to teach, with 88% selecting “very” or “extremely.” The INTERACT2 program was perceived to have a neutral or positive impact on time management, workflow, and stress levels, and it was seen as enhancing the learning environment, with all supervisors reporting a positive effect (Table 4).\u003c/p\u003e\n\u003cp\u003eRegistrars reported needing to take initiative with organisational tasks relevant to teaching such as negotiating time off during work hours and coordinating with practice managers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I know for me like there was quite a bit of leg work I did have to do, even just to kind of get the time off to attend the teaching sessions [be]cause it was on my, you know, during my work hours and then following it up with the practice manager and that sort of thing... ”\u003c/em\u003e \u003cstrong\u003eGP registrar 1- focus group, phase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Response rates to the surveys are recorded in the appendix.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of our study was to create a model that could be scaled state or nationwide and become a routine part of GP training. Our study is novel by demonstrating an approach that can improve teaching confidence, teaching participation and engagement in early career doctors. Furthermore, this study actively involved other crucial stakeholders, namely medical students and GP supervisors, underscoring the collaborative nature of the proposed model. With the right timing and availability of learners such as medical students our intervention can be scalable and equip GP registrars with teaching skills to foster the next generation of doctors. The study could also translate to faculty development in allied health professions who have community work-based learning such as physiotherapy, social work, occupational therapy, optometry, etc. The components of our model could also be applied in other countries where training of health professionals includes community settings.\u003c/p\u003e\u003cp\u003eOur study supports the view that GP registrars can positively impact the learning environment in general practice when supported by a structured teacher training framework, dedicated teaching sessions, and support from practices and GP supervisors. During the study, we observed the emergence of a dual professional identity in GP registrars, blending their roles as educators and clinicians. This aligns with findings from other research (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), highlighting similar outcomes among GP registrars involved in multilevel teaching initiatives.\u003c/p\u003e\u003cp\u003eThe benefits, barriers and facilitators of multilevel learning and near-peer teaching for GP registrars are well studied (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Similar findings such as improved teaching culture, medical student engagement, and workflow were congruent with published data. Barriers such as time, availability and scheduling of medical students were also confirmed (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study was unique in its co-design approach, which empowered registrars, enhanced confidence, and improved readiness to teach. Our iterative approach further refined the model, leading to shortened upfront teacher training and supplementary teaching materials summarising key techniques, ensuring a feasible and sustainable integration of teaching into GP registrar training.\u003c/p\u003e\u003cp\u003eIt has been established that GP registrar-led teaching sessions can empower motivated registrars to gain teaching experience while deepening their own learning (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This study supports the notion that GP registrars are self-regulated learners (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) who, with adequate support, can take initiative in organising their teaching opportunities. However, this empowerment may come at a cost, as registrars might spend valuable training time coordinating and preparing for teaching sessions. Previous research highlights the numerous competing priorities already faced by GP registrars (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In reality, this \u0026lsquo;time commitment\u0026rsquo; can be mitigated by sharing or delegating this co-ordination role with the practice manager. A key strength of this project was its flexibility\u0026mdash;neither the duration nor the format of the teaching activities were prescribed which provided the registrars with agency and control over their teaching role.\u003c/p\u003e\u003cp\u003eGP registrars, medical students, and GP supervisors expressed some hesitation about recommending early registrars to teach medical students, citing the registrars' relative inexperience and the increased cognitive demands of transitioning to primary care, which is also consistent with other studies (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). This study included very few GPT1 participants, which may reflect a degree of self-exclusion by GPT1 registrars. However, this hesitancy must be balanced against the risk of sidelining valuable teaching experience, as highlighted in discussions with registrars who had prior teaching experience but reported neglecting it during their GP training. These dynamics align with Keegan\u0026rsquo;s stages of professional identity formation, where learners transition from dependent, rule-based novices to more autonomous, adaptive professionals (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Early registrars may hesitate to teach due to a lack of confidence or identity as educators, but structured teaching roles could support their professional development by reinforcing their dual identity as both learners and teachers.\u003c/p\u003e\u003cp\u003eFurthermore, times of discomfort can serve as accelerants for professional identity formation, as individuals are often forced to reevaluate and solidify their sense of self in challenging or uncertain conditions (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Our study\u0026mdash;along with the authors\u0026rsquo; own experiences\u0026mdash;highlighted that teaching can be an uncomfortable yet transformative experience, particularly for those early in their careers. This aligns with Bjork\u0026rsquo;s \u0026ldquo;Desirable Difficulties\u0026rdquo; framework, which posits that learning is more durable when it involves effortful engagement and challenge (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese principles further align with Vygotsky's Zone of Proximal Development, which emphasises that learners develop most effectively when given tasks slightly beyond their current capabilities, provided they receive adequate scaffolding and support (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Encouraging supervised teaching opportunities for early GP registrars could therefore serve as both a learning and identity-forming experience, reinforcing their development as confident and capable clinicians.\u003c/p\u003e\u003cp\u003eThere is a notable absence of structured teaching to equip registrars with teaching skills within the Australian GP registrar training program (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and in countries with comparable training models, such as the UK (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Given the clear benefits of near-peer teaching, we encourage professional bodies, supervisors, and practices to actively support and facilitate registrar-led teaching opportunities for medical students. Rather than a passive or ad-hoc approach, teaching should be recognised as a valuable component of registrar training and professional development, implemented flexibly based on individual readiness and institutional support.\u003c/p\u003e\u003cp\u003eThis study was the first to explore how practices generally distribute their teaching income and how registrars were allocated teaching payments when assigned formalized teaching sessions. We observed significant variability in how teaching payments were distributed to registrars. Previous research has highlighted the need for greater transparency in teaching-related funding allocation (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This study found that both GP supervisors and GP registrars generally agreed that registrars should be remunerated for their teaching time. However, how to best align this with current collective employment contracts warrants further attention.\u003c/p\u003e\u003cp\u003ePrevious studies reported that some GP registrars thought that teaching would occur outside of training time (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). As part of our stakeholder engagement, we were able to gain clarification from the RACGP Victorian Censor that training time could be counted towards training which can further incentivise GP registrars to teach.\u003c/p\u003e\u003cp\u003eThis study aligns with existing literature suggesting that, despite challenges, near-peer teaching offers significant benefits (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our findings revealed that medical students responded very positively to the experience and expressed increased interest in pursuing general practice as a career (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Feedback from GP supervisors was also favourable, with most reporting neutral or positive effects on their workflow and stress levels.\u003c/p\u003e\u003cp\u003eFrom a policy point of view, the number of the medical students are expanding and the need for greater number of general practitioners is also high on the agenda for many countries (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Clinical training places for medical students in general practice has been identified as a solution to the training shortfall (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). There is also recognition of community-based learning experiences being of high relevancy to the foundations of patient care and relevant to the health needs of our population (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Furthermore, there is a shortage of GP educator workforce (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). GP registrars may be an untapped resource which can fill the gap in educators of medical students and further encourage students to choose general practice as a career pathway.\u003c/p\u003e\u003cp\u003eMulti-level learning involving registrars and medical students will require input from relevant training organisations and universities. A teaching training session could therefore be collaboratively provided by the GP training programs and medical schools (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Explicit guidance informed by our model could help facilitate near-peer teaching sessions and provide essential support for registrars in their teaching roles.\u003c/p\u003e\u003cp\u003eThis study had some limitations. We were not able to delineate a direct correlation between our model and improved readiness to teach, but we can deduce from other literature (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) that the provision of training followed by an opportunity to teach are likely contributing factors. The response rate to the phase 2 survey of GP supervisors of 44% was lower than the 83% response rate in the smaller phase 1 cohort. We hypothesise that this decline was due to lower engagement, as the phase 2 GP registrars were not involved in co-design and our distribution of surveys was predominantly driven by registrars. As mentioned, our study tended to have more experienced registrars from metropolitan areas and may not be transferrable to early GP registrars and other geographical locations.\u003c/p\u003e\u003cp\u003eThis study demonstrates that with appropriate training, support, and institutional awareness, GP registrars can confidently take the helm as educators within a multi-level learning framework. By charting a co-designed approach the study enhanced registrars' confidence and readiness to teach, contributing to their professional development and enriching medical education in general practice. The findings reinforce the mutual benefits of near-peer teaching for GP registrars, medical students and GP supervisors while also highlighting the need for structured teaching programs, clearer funding policies and stronger institutional supports to facilitate GP registrars as educators in the clinical setting.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAGPT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAustralian General Practice Training Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFTAs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFailure to Attend\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGPT1\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral practice term 1\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINTERACT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntegrating Registrars As Clinical Teachers (Project)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePIP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePractice incentive payment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRACGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRoyal Australian College of General Practitioners\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVicREN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVictorian Primary Care Practice-based Research and Education Network\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this project was granted by the Human Ethics Team at the University of Melbourne. Reference Number:2024-29154-53087-2. All participants received written information about the study and provided informed consent prior to participation. The authors conducted the study in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets generated from this study are not publicly available due to ethical and privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have completed the ICMJE uniform disclosure form and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research project is supported by the Royal Australian College of General Practitioners (RACGP) through the 2023 Education Research grant ERG2024-08 and by the Richard Gilmour-Smith Research Trust grant 051633. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. HL wrote the manuscript, conducted the qualitative analysis, generated initial codes, and developed themes. CJ conceived the study and helped develop the analytical framework. DRD prepared Tables 1–5 and helped analyse the data. Early codes were sense-checked by AW and DRD. RS helped analyse the quantitative data. All authors contributed to the study’s conceptual development, provided methodological or analytical input, edited the manuscript, and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the following individuals for their invaluable contributions as stakeholders in this study:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Niroshe Amarasekera, Dr. Katie Fisher, Jane Henty, Dr. Stephanie Parker, Dr. Morgan Raynor, Dr. Angelina Salamone, Dr. Wonie Uahwatanasakul, Dr. Ed Vergara, Bianca Vardanega, and Jasmine Yip.\u003c/p\u003e\n\u003cp\u003eWe also extend our appreciation to all study participants, whose valuable time and contributions provided critical insights into the experiences and realities of GP registrars engaged in teaching. The participants and stakeholders were instrumental in shaping the co-design and implementation of this project. Their perspectives enriched our understanding of the challenges and facilitators in integrating teaching into GP training, ensuring that our findings are both relevant and applicable to real-world educational practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot commissioned; externally peer reviewed.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAustralia Government DoH, Care A. GP Supply and Demand Study Compendium - August 2024 2024 [Available from: https://hwd.health.gov.au/resources/primary/gp-supply-and-demand-study-compendium-august-2024.pdf.\u003c/li\u003e\n\u003cli\u003eLandstrom B, Mattsson B, Nordin P, Rudebeck CE. The characteristics of general practice and the attractiveness of working as a GP: medical students views. 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VICREN \u0026ndash; Victorian Primary Care Research and Education Network: The University of Melbourne; 2024 [Available from: https://medicine.unimelb.edu.au/school-structure/general-practice-and-primary-care/engagement/primary-care-community/research/vicren.\u003c/li\u003e\n\u003cli\u003eAustralia S. Practice Incentives Program Teaching Payment Guidelines Effective 1 August 2024 2024 [Available from: https://www.servicesaustralia.gov.au/sites/default/files/2024-08/teaching-payment-pip-guidelines-2.docx.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology. 2021;18(3):328-52.\u003c/li\u003e\n\u003cli\u003eDick MLB, King DB, Mitchell GK, Kelly GD, Buckley JF, Garside SJ. Vertical integration in teaching and learning (VITAL): an approach to medical education in general practice. 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Education for Primary Care. 2019;30(6):347-54.\u003c/li\u003e\n\u003cli\u003eSilberberg P, Ahern C, van de Mortel TF. \u0026lsquo;Learners as teachers\u0026rsquo; in general practice: stakeholders\u0026rsquo; views of the benefits and issues. Education for Primary Care. 2013;24(6):410-7.\u003c/li\u003e\n\u003cli\u003eKegan R. In Over Our Heads: The Mental Demands of Modern Life. Harvard University Press1994.\u003c/li\u003e\n\u003cli\u003eLewin LO, McManamon A, Stein MTO, Chen DT. Minding the form that transforms: using Kegan\u0026apos;s model of adult development to understand personal and professional identity formation in medicine. Acad Med. 2019;94(9):1299-304.\u003c/li\u003e\n\u003cli\u003eBrown ME, Lim JH, Horsburgh J, Pistoll C, Thakerar V, Maini A, et al. Identity development in disorientating times: the experiences of medical students during COVID-19. Medical Science Educator. 2022;32(5):995-1004.\u003c/li\u003e\n\u003cli\u003eBjork RA, Bjork EL. Desirable difficulties in theory and practice. Journal of Applied research in Memory and Cognition. 2020;9(4):475.\u003c/li\u003e\n\u003cli\u003eVygotsky L. Mind in Society: The Development of Higher Psychological Processes. Harvard University Press1978.\u003c/li\u003e\n\u003cli\u003eZealand MDAaN. Position Paper: The Doctors our Communities Need: Building, Sustaining and Supporting the General Practice Workforce in Australia and New Zealand. Sydney, Australia 2023 [Available from: efaidnbmnnnibpcajpcglclefindmkaj/https://medicaldeans.org.au/md/2023/10/The-Doctors-our-comminity-needs-Medical-Deans-Position-Paper-2023.pdf.\u003c/li\u003e\n\u003cli\u003e(UK) MSC. The expansion of medical student numbers [13/05/2025]. Available from: https://www.medschools.ac.uk/our-work/the-expansion-of-medical-student-numbers.\u003c/li\u003e\n\u003cli\u003eUsherwood T, Mishra A, Knight A. Registrars are teachers too! Medical Education. 2004;38(11):1189-90.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Near-peer teaching, GP registrar education, medical student learning, general practice training","lastPublishedDoi":"10.21203/rs.3.rs-7379385/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7379385/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGP registrars are an underutilised resource within the GP and medical student education. While many GP registrars informally contribute to the training of future doctors, their provision of teaching is often unstructured and ad hoc because of the lack of formalised pathways for teaching. Near-peer teaching, where a learner teaches another learner at a more junior or similar stage of training, offers an approach that can enhance both teaching and learning experiences. This study aims to provide a framework for GP registrars to teach with the goal of integrating and scaling this approach within GP training. The study evaluated the impact of providing registrars with teacher training and the impact of the resulting teaching activity on stakeholders.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods and Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study was conducted in two sequential phases. Phase 1 used a small group of participants across three stakeholder groups: GP registrars (n\u0026thinsp;=\u0026thinsp;8), GP supervisors (n\u0026thinsp;=\u0026thinsp;5), Medical students (n\u0026thinsp;=\u0026thinsp;7) to codesign a pilot intervention that included teacher training and teaching opportunities. Data was collected using focus groups and surveys. Phase 2, used iterative feedback to optimise and implement the intervention with a larger group of GP registrars (n\u0026thinsp;=\u0026thinsp;18). Data was obtained from surveys. We used reflexive thematic analysis and descriptive statistics to analyse data from both phases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study illustrates a real-world application of GP registrars engaging in near-peer teaching in a supported and semi-structured manner. This study revealed three key themes. 1. Evolution of an educator identity, 2. Workflow integration, 3. Stakeholder collaboration. As a result of the project, the GP registrars reported increased confidence, competence and the development of dual professional identity as clinicians and educators. While there were some trade-offs, such as time and financial considerations, the teaching experience and professional development were generally valued by registrars. Medical students and other learners also valued the diverse teaching styles provided by an expanded teaching faculty. GP supervisors reported neutral or positive effects on their workflow and stress levels.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStructured guidance and support can encourage and enable GP registrars to successfully teach near-peers in the primary care setting. Clearer renumeration pathways may further incentivise GP registrars to participate in near-peer teaching. Central training organisations can play a pivotal role in facilitating broader rollouts or trials and promote the development of teaching skills as an integral part of GP training. Such initiatives not only enhance the educational experience for medical students but also contribute to the professional development of registrars and the overall quality of primary care education.\u003c/p\u003e","manuscriptTitle":"Empowering GP registrars as near-peer teachers in general practice: a mixed methods exploration of a co-designed intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 10:57:48","doi":"10.21203/rs.3.rs-7379385/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-04T22:54:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129554908288708210806545360789094830174","date":"2025-11-04T22:16:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T16:42:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T10:06:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-30T06:26:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-30T04:28:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-27T06:08:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5088aecf-03d7-42a6-b291-4ae3ea72d7e8","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-06T10:57:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 10:57:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7379385","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7379385","identity":"rs-7379385","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}