Challenges to children’s health care in an ageing Australia

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146587/1/mja2436.pd

Colleague appraisal of Australian general practitioners in training: an analysis of multisource feedback data

Background: Multisource feedback is an evidence-based and validated tool used to provide clinicians, including those in training, feedback on their professional and interpersonal skills. Multisource feedback is mandatory for participants in the Royal Australian College of General Practitioners Practice Experience Program and for some Australian General Practice Training Registrars. Given the recency of the Practice Experience Program, there are currently no benchmarks available for comparison within the program and to other comparable cohorts including doctors in the Australian General Practice Training program. The aim of this study is to evaluate and compare colleague feedback within and across General Practice trainee cohorts. Methods: Colleague feedback, from multisource feedback of Practice Experience Program participants and Australian General Practice Training Registrars, collected between January 2018 and April 2020, was compared to identify similarities and differences. Analyses entailed descriptive statistics, between and within groups rater consistency and agreement measures, principal component analysis, t-tests, analysis of variance, and psychometric network analysis. Results: Colleague ratings of Practice Experience Program participants (overall average 88.58%) were lower than for Registrars (89.08%), although this difference was not significant. ‘Communication with patients’ was rated significantly lower for Practice Experience Program participants (2.13%) while this group was rated significantly better for their ‘Ability to say no’ (1.78%). Psychometric network analyses showed stronger linkages between items making up the behavioural component (compared to the items of the performance and self-management components, as found by principal component analysis) for Practice Experience Program participants as compared to Registrars. Practice Experience Program participants were stronger in clinical knowledge and skills as well as confidentiality, while Registrars were stronger in communicating with patients, managing their own stress, and in their management and leadership skills. Conclusions: The multisource feedback scores of doctors undertaking the Practice Experience Program suggests that, while all mean values are ‘very good’ to ‘excellent’, there are areas for improvement. The linkages between skills suggests that Practice Experience Program doctors’ skills are somewhat isolated and have yet to fully synthesise. We now have a better understanding of how different groups of General Practitioners in training compare with respect to professional and interpersonal skills. Based on the demonstrated differences, the Practice Experience Program might benefit from the addition of educational activities to target the less developed skills

Changes in longer consultations for children in general practice

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97524/1/jpc12157.pd

A comparison of patient appraisal of professional skills for GPs in training participating in differing education programs

Background: Medical boards and healthcare providers internationally are coming under increasing pressure to attract international medical graduates (IMGs) and overseas trained doctors (OTDs) to cope with predicted general practice (GP) doctor shortages. Various pathways to registration are made available for this purpose. There is very little understanding of the effects of different training pathways to licensing and registration on the ability of IMGs and OTDs, as well as locally trained doctors, to acquire the desirable professional skills deemed necessary for working effectively in the primary care sector. Methods: Feedback from patients was collected at the end of their scheduled consultation with their doctor using a questionnaire consisting of 13 Likert scale items that asked them to rate their experience of the consultation. Feedback was obtained for doctors going through the Royal Australian College of General Practice (RACGP) Practice Experience Program (PEP) and the Australian General Practice Training Program (AGPT), with the former intended primarily for IMGs and OTDs, and the latter for local medical graduates including from New Zealand. Patient feedback was also obtained for patients visiting already Fellowed and experienced GPs for comparative purposes, resulting in data for three groups of doctors (two trainee, one already Fellowed). Rater consistency and agreement measures, analysis of variance, principal component analysis, t-tests and psychometric network analysis were undertaken between and within groups to identify similarities and differences in patient experience and professionalism of doctors. Results: There was a small but significant difference in average patient raw scores given to PEP and AGPT doctors (90.25, 90.97%), with the highest scores for ‘Respect shown’ (92.24, 93.15%) and the lowest for ‘Reassurance’ 89.38, 89.84%). Male patients gave lower scores (89.56%) than female patients (91.23%) for both groups of doctors. In comparison, patients gave experienced GPs an average 91.38% score, with male patients giving a lower average score than female patients (90.62, 91.93%). Two components were found in the patient data (interpersonal communication, caring/empathy) that account for over 80% of the variance. When patient scores were aggregated by doctor, the average PEP and AGPT doctor scores received were 90.27 and 90.99%, in comparison to the average experienced GP score of 91.43%. Network analysis revealed differences in the connectedness of items between these two groups as well as in comparison with experienced GPs, suggesting that PEP doctors’ skills are less cohesively developed in the areas of listening ability, explaining and providing reassurance. Conclusions: The small but statistically significant differences between doctor groups reported in this preliminary study are supplemented by percentile analysis, network analysis and principal component analysis to identify areas for further exploration and study. There is scope for improving the integration of interpersonal communication skills of GPs in Training with their caring and empathy skills, when compared with experienced GPs as a benchmark. Suggestions are made for enhancing professional skills from a patients’ perspective in future training programs

General practice registrars’ clinical uncertainty, and in-consultation information- and assistance-seeking

Purpose: To explore the association of Australian general practitioner (GP) registrars’ responses to uncertainty with their in-consultation information-, advice- and assistance-seeking.Design/methodology/approach: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) cohort study in four Australian states. In ReCEnT, GP registrars record details of 60 consecutive consultations, six-monthly, three times during training.Outcome factors in logistic regression models included whether the registrar sought in-consultation information or assistance from (i) their supervisor or (ii) an electronic or paper-based source. Independent variables were the four independent subscales of the Physicians’ Reaction to Uncertainty (PRU) instrument, as well as registrar, practice and consultation variables.Findings: 589 registrars contributed details of 70,412 consultations.On multivariable analysis, scores on the two ‘affective’ PRU subscales ‘anxiety regarding diagnosis/management’ (OR 1.03; 95% confidence intervals [CIs] [1.01, 1.05], p = 0.003) and ‘concern about a bad outcome’ (OR 1.03; 95% CIs [1.01, 1.06], p = 0.008) were significantly associated with seeking supervisor assistance. There was no association with ‘behavioural’ subscales ‘reluctance to disclose uncertainty to patients’ and ‘reluctance to disclose mistakes to physicians’.None of the PRU subscales were significantly associated with information-seeking from electronic or hard copy sources.Research implications: Further research is required to explore the role of uncertainty within registrar–supervisor interactions and to define the role of supervisors in registrars’ functional adaptation to clinical uncertainty (including how best to support and train supervisors in this role).Practical implications: GP registrars’ ‘affective’ responses to clinical uncertainty are associated with assistance-seeking from clinical supervisors. While in-consultation assistance-seeking may promote registrars’ tolerance of uncertainty, it may also contribute to supervisor workload.Originality/value: This is the first study to examine trainees’ levels of uncertainty and their seeking of information and assistance.Limitations: We have not investigated whether registrars’ seeking assistance resolved or attenuated, for the index problem, their anxiety or concern

Emergency department referral patterns of Australian general practitioner registrars: A cross-sectional analysis of prevalence, nature and associations

Objective: Limited international evidence suggests general practice registrars' emergency department (ED) referral rates exceed those of established general practitioners (GPs). The aim of the present study was to fill an evidence gap by establishing the prevalence, nature and associations of Australian GP registrar ED referrals. Methods: A cross-sectional analysis was performed of the Registrar Clinical Encounters in Training (ReCEnT) cohort study of GP registrars' consultation experiences, between 2010 and 2015. The outcome factor in logistic regression analysis was referral to an ED. Independent variables included patient-level, registrar-level, practice-level and consultation-level factors. Results: In all, 1161 GP registrars (response rate 95.5%) contributed data from 166 966 consultations, comprising 258 381 individual problems. Based on responses, 0.5% of problems resulted in ED referral, of which nearly 25% comprised chest pain, abdominal pain and fractures. Significant (P 34 years, the patient being new to the registrar, one particular regional training provider (RTP), in-consultation information or assistance being sought and learning goals being generated. Outer regional-, remote-or very remote-based registrars made significantly fewer ED referrals than more urban registrars. Of the problems referred to the ED, 45.5% involved the seeking of in-consultation information or assistance, predominantly from supervisors. Conclusions: Registrars' ED referral rates are nearly twice those of established GPs. The findings of the present study suggest acute illnesses or injuries present registrars with clinical challenges and real learning opportunities, and highlight the importance of continuity of care, even for acute presentations

Investigation of fatigue by Australian General Practice Registrars: a cross-sectional study

INTRODUCTION: Fatigue is the most common undifferentiated problem presenting in general practice. Previous studies have shown that this presentation leads to multiple investigations. There is no published literature describing the management of patients with fatigue by general practice (GP) registrars. AIM: To document the investigation-ordering behaviour of GP registrars in managing patients with a new diagnosis of unexplained fatigue. METHODS: This was a cross-sectional analysis of data from Registrar Clinical Encounters in Training (ReCEnT), an ongoing cohort study of GP registrars’ consultations. We established the prevalence of new diagnoses of unexplained fatigue and associations with that diagnosis, the rate of test ordering and the number and types of investigations ordered. RESULTS: 644 registrars contributed data from 68 986 encounters. In 0.78% of patient encounters, a new diagnosis of unexplained fatigue was made. Pathology was ordered in 78.4% of these problems (versus 18.1% in non-fatigue problems), at a rate of 488 tests per 100 new fatigue problems. DISCUSSION: Our study suggests that unexplained fatigue elicits a non-rational approach to test ordering by registrars. These findings contribute to the understanding of GP registrar management of fatigue, and undifferentiated presentations more broadly, and suggest educational approaches to improve practice, including dealing with uncertainty

Prevalence and associations of General Practice registrars’ management of Impetigo: a cross-sectional analysis from the registrar clinical encounters in training (ReCEnT) study

Background: Impetigo is a mild bacterial skin infection of childhood that is usually managed empirically in primary care. Objective: To establish the prevalence and associations of impetigo in general practice (GP) registrars’ consultations. Methods: Cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study data. Results: Impetigo was managed in 0.24% of problems and 0.43% of consultations. Patient variables associated with impetigo presentations were younger age and impetigo as a new problem, while patients with non–English-speaking backgrounds were less likely to present with impetigo. Associated registrar variables were being new to the registrar and practicing in outer regional/remote locations. Compared with all other problems/diagnoses, impetigo more often involved information seeking, ordering pathology, and prescription of medication, but less often involved follow-up or referral. Conclusions: Impetigo accounts for 0.43 per 100 GP registrar consultations in Australia. Association with outer regional/remote areas may reflect climate and socioeconomic factors that predispose to impetigo. Associated pathology requests may reflect a lack of confidence in GP registrars’ management of impetigo. Cultural differences may exist regarding health-seeking behavior relating to impetigo

Transitions in general practice training : quantifying epidemiological variation in trainees' experiences and clinical behaviours

Background: General Practice training in Australia is delivered through the apprenticeship model. General Practice supervisors support trainees transitioning from hospital-based work towards competent independent community-based practice. The timing and manner in which support should be provided is still not well understood. This study aimed to establish the variation in clinical and educational experiences and behaviours, and location, of general practice trainees’ consultations by stage of their vocational training. It was hypothesised that change is greater in earlier stages of training. Methods: A cross-sectional analysis of data (2010–2018) from the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing cohort study of Australian GP registrars’ in-consultation clinical and educational experience and behaviours. Multinomial logistic regression assessed the association of demographic, educational, and clinical factors in different stages of training. The outcome factor was the training term. Results: Two thousand four hundred sixteen registrars contributed data for 321,414 patient consultations. For several important variables (seeing patients with chronic disease; new patients; seeking in-consultation information or assistance; ordering pathology and imaging; and working in a small or regional practice), odds ratios were considerably greater for comparisons of Term 1 and 3, relative to comparisons of Term 2 and 3. Conclusion: Differences experienced in demographic, clinical and educational factors are significantly more pronounced earlier in registrars’ training. This funding has educational and training implications with respect to resource allocation, trainee supervision and curriculum design. Sociocultural learning theory enables an understanding of the impact of transitions on, and how to support, general practice trainees and supervisors

Australian general practice trainees’ exposure to ophthalmic problems and implications for training: A cross-sectional analysis

INTRODUCTION: Eye conditions are common presentations in Australian general practice, with the potential for serious sequelae. Pre-vocational ophthalmology training for General Practitioner (GP) trainees is limited. AIM: To describe the rate, nature and associations of ophthalmic problems managed by Australian GP trainees, and derive implications for education and training. METHODS: Cross-sectional analysis from an ongoing cohort study of GP trainees’ clinical consultations. Trainees recorded demographic, clinical and educational details of consecutive patient consultations. Descriptive analyses report trainee, patient and practice demographics. Proportions of all problems managed in these consultations that were ophthalmology-related were calculated with 95% confidence intervals (CI). Associations were tested using simple logistic regression within the generalised estimating equations (GEE) framework. RESULTS: In total, 884 trainees returned data on 184,476 individual problems or diagnoses from 118,541 encounters. There were 2649 ophthalmology-related problems, equating to 1.4% (95% CI: 1.38-1.49) of all problems managed. The most common eye presentations were conjunctivitis (32.5% of total problems), eyelid problems (14.9%), foreign body (5.3%) and dry eye (4.7%). Statistically significant associations were male trainee; male patient and patient aged 14 years or under; the problem being new and the patient being new to both trainee and practice; urban and of higher socioeconomic status practice location; the practice nurse not being involved; planned follow up not arranged; referral made; in-consultation information sought; and learning goals generated. DISCUSSION: Trainees have comparable ophthalmology exposure to established GPs. However, associations with referral and information-seeking suggest GP trainees find ophthalmic problems challenging, reinforcing the critical importance of appropriate training