Study protocol: the Registrar Clinical Encounters in Training (ReCEnT) study.
ABSTRACT: BACKGROUND: Patient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars. METHODS/DESIGN: This is an ongoing prospective multi-site cohort study of general practice registrars' consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program. CONCLUSIONS: The study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap - the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars' patterns of practice (for example, prescribing practice) over the course of their training.
Project description:BACKGROUND:Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing. OBJECTIVE:To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years. MAIN MEASURES:The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015). KEY RESULTS:Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]). CONCLUSIONS:Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.
Project description:<h4>Objective</h4>To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18?months in general practice).<h4>Design</h4>A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study.<h4>Setting</h4>ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states.<h4>Participants</h4>Registrars participating in ReCEnT from 2010 to 2017.<h4>Outcome measures</h4>Management of impetigo with systemic antibiotics.<h4>Results</h4>1741 registrars (response rate 96%) provided data from 384?731 problems identified in 246?434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95%?CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95%?CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95%?CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95%?CI 1.37 to 3.33; p=0.01).<h4>Conclusions</h4>Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.
Project description:BACKGROUND:In Australia registrar training to become a general practitioner (GP) involves three to four years of supervised learning with at least 50% of GP registrars training wholly in rural areas. In particular rural over regional GP placements are important for developing future GPs with broader skills because the rural scope of practice is wider. Having enough GP supervisors in smaller rural communities is essential such training. We aimed to explore what makes rural GPs' based outside of major regional centres, participate in supervising or not, their experiences of supervising, and impact of their practice context. METHODS:Semi-structured interviews were undertaken with 25 GPs based in rural Tasmania (outside of major regions - Hobart and Launceston), in towns of <?25,000 population, to explore the GPs' professional backgrounds, their experiences of supervising GP registrars, their practice context and their decisions about supervising GP registrars or not. Thematic analysis was undertaken; key ideas, concepts and experiences were identified and then reviewed and further refined to core themes. RESULTS:Supervising was perceived to positively impact on quality of clinical care, reduce busy-ness and improve patient access to primary care. It was energising for GPs working in rural contexts. Rural GPs noted business factors impacted the decision to participate in supervision and the experience of participating: including uncertainty and discontinuity of registrar supply (rotational training systems), registrar competence and generating income. CONCLUSIONS:Supervising is strongly positive for rural GPs and related to job satisfaction but increasing supervision capacity in rural areas may depend on better policies to assure continuity of rural registrars as well as policies and systems that enable viable supervision models tailored to the context.
Project description:The main aim of the study was to investigate how many and what kind of problems patients present in consultations with their general practitioner (GP). A secondary aim was to explore patients' views on what is important in consultations.Cross-sectional study including observation of unselected consultations with recording on a pre-designed scheme, and a brief questionnaire filled in by patients.Four general practices in Oslo, Norway.A total of 201 patients in consultations and 177 patients waiting to see their GP.Number and characteristics of problems raised by patients, and whether the problems were handled by GPs during the ongoing consultation. Patients' expectations for the consultation.The mean number of problems raised was 2.6 (range 1-16), and when appointments for acute conditions were excluded, the mean number was 3.3. Somatic problems comprised about half of all problems, and in more than one-quarter of consultations a mental health issue was presented. Female sex and increasing age predicted an increasing number of problems raised. In one-quarter of encounters four or more problems were presented. The vast majority of problems were dealt with by the GPs during the ongoing consultation. "That I am able to address all the problems I have" was rated as highly important by patients.GPs deal with multiple and unrelated problems in daily consultations, which is highly valued by patients. Management of concurrent problems in brief encounters demands training and adequate working conditions, in order to sustain this core value of general practice.
Project description:OBJECTIVES:Consultation duration has previously been shown to be associated with patient, practitioner and practice characteristics. However, previous studies were conducted outside the UK, considered only small numbers of general practitioner (GP) consultations or focused primarily on practitioner-level characteristics. We aimed to determine the patient-level and practice-level factors associated with duration of GP and nurse consultations in UK primary care. DESIGN AND SETTING:Cross-sectional data were obtained from English general practices contributing to the Clinical Practice Research Datalink (CPRD) linked to data on patient deprivation and practice staffing, rurality and Quality and Outcomes Framework (QOF) achievement. PARTICIPANTS:218?304 patients, from 316 English general practices, consulting from 1 April 2013 to 31 March 2014. ANALYSIS:Multilevel mixed-effects models described the association between consultation duration and patient-level and practice-level factors (patient age, gender, smoking status, ethnic group, deprivation and practice rurality, number of full-time equivalent GPs/nurses, list size, consultation rate, quintile of overall QOF achievement and training status). RESULTS:Mean duration of face-to-face GP consultations was 9.24?min and 5.32?min for telephone consultations. Nurse face-to-face and telephone consultations lasted 9.70 and 5.73?min on average, respectively. Longer GP consultation duration was associated with female patient gender, practice training status and older patient age. Shorter duration was associated with higher deprivation and consultation rate. Longer nurse consultation duration was associated with male patient gender, older patient age and ever smoking; and shorter duration with higher consultation rate. Observed differences in duration were small (eg, GP consultations with female patients compared with male patients were 8?s longer on average). CONCLUSIONS:Small observed differences in consultation duration indicate that patients are treated similarly regardless of background. Increased consultation duration may be beneficial for older or comorbid patients, but the benefits and costs of increased consultation duration require further study.
Project description:OBJECTIVE:To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis. DESIGN:A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22?million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation. SETTING:General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand. PARTICIPANTS:Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded. MAIN OUTCOME MEASURES:The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice. RESULTS:Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10?000 patient-years (95%?CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10?000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis. CONCLUSIONS:Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.
Project description:BACKGROUND:Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM. METHODS:In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n =?31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n =?194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made. RESULTS:The oncologist training had a large positive effect on observed SDM (Cohen's d =?1.12) and on patient-reported SDM (d =?0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made. CONCLUSION:Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice. TRIAL REGISTRATION:Netherlands Trial Registry NTR 5489. IMPLICATIONS FOR PRACTICE:Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n =?194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.
Project description:To ascertain the issues all general practice educators need to understand when educating GP registrars to learn about research.A review of MEDLINE [1996-2007], six websites and key informants produced 302 publications, which reduced to 35 articles, 7 books, and 9 policy documents.Key themes that emerged from a thematic analysis of the literature that GP educators need to consider when teaching registrars about research were [i] the need to understand that learning research is influenced by attitudes; [ii] the need to address organisational constraints on learning research; [iii] the need to identify the educational barriers on learning research; [iv] the need to understand there are gaps in GP research content - especially from GP registrars; And [v] the need to understand the value of research on the GP registrar's educational cycle of learning, which develops in a culture that allows research to flourish.Australian GP registrars will observe a research culture only if they encounter clinician-researchers paid to practice and conduct research in their general practice.
Project description:INTRODUCTION:General practice in Australia, as in many countries, faces challenges in the areas of workforce capacity and workforce distribution. General practice vocational training in Australia not only addresses the training of competent independent general practitioners (GPs) but also addresses these workforce issues. This study aims to establish the prevalence and associations of early career (within 2 years of completion of vocational training) GPs' practice characteristics; and also to establish their perceptions of utility of their training in preparing them for independent practice. METHODS AND ANALYSIS:This will be a cross-sectional questionnaire study. Participants will be former registrars ('alumni') of three regional training organisations (RTOs) who achieved general practice Fellowship (qualifying them for independent practice) between January 2016 and July 2018 inclusive. The questionnaire data will be linked to data collected as part of the participants' educational programme with the RTOs. Outcomes will include alumni rurality of practice; socioeconomic status of practice; retention within their RTO's geographic footprint; workload; provision of nursing home care, after-hours care and home visits; and involvement in general practice teaching and supervision. Associations of these outcomes will be established with logistic regression. The utility of RTO-provided training versus in-practice training in preparing the early career GP for unsupervised post-Ffellowship practice in particular aspects of practice will be assessed with χ2 tests. ETHICS AND DISSEMINATION:Ethics approval is by the University of Newcastle Human Research Ethics Committee, approval numbers H-2018-0333 and H-2009-0323. The findings of this study will be widely disseminated via conference presentations and publication in peer-reviewed journals, educational practice translational workshops and the GP Synergy Research subwebsite.
Project description:OBJECTIVE:Since many years, teaching and training in communication skills are cornerstones in the medical education curriculum. Although video recording in a real-time consultation is expected to positively contribute to the learning process, research on this topic is scarce. This study will focus on the feasibility and acceptability of video recording during real-time patient encounters performed by general practitioner (GP) trainees. METHOD:The primary research question addressed the experiences (defined as feasibility and acceptability) of GP trainees in video-recorded vocational training in a general practice. The second research question addressed the appraisal of this training. The procedure of video-recorded training is developed, refined and validated by the Academic Teaching Practice of Leuven since 1974 (Faculty of Medicine of the University of Leuven). The study is set up as a cross-sectional survey without follow-up. Outcome measures were defined as 'feasibility and acceptability' (experiences of trainees) of the video-recorded training and were approached by a structured questionnaire with the opportunity to add free text comments. The studied sample consisted of all first-phase trainees of the GP Master 2011-2012 at the University of Leuven. RESULTS:Almost 70% of the trainees were positive about recording consultations. Nevertheless, over 60% believed that patients felt uncomfortable during the video-recorded encounter. Almost 90% noticed an improvement of own communication skills through the observation and evaluation of. Most students (85%) experienced the logistical issues as major barrier to perform video consultations on a regular base. CONCLUSIONS:This study lays the foundation stone for further exploration of the video training in real-time consultations. Both students and teachers on the field acknowledge that the power of imaging is underestimated in the training of communication and vocational skills. The development of supportive material and protocols will lower thresholds. PRACTICE IMPLICATIONS:Time investment for teachers could be tempered by bringing up students to peer tutors and by an accurate scheduling of the video training. The development of supportive material and protocols will lower thresholds. Further research should finally focus on long-term efficacy and efficiency in terms of learning outcomes and on the facilitation of the technical process.