Correction to: Multisource feedback as part of the medical board of Australia's professional performance framework: outcomes from a preliminary study.

Following publication of the original article [1], the author reported that Fig. 4 was missing. This has now been corrected in the original article.

Multisource feedback as part of the Medical Board of Australia's Professional Performance Framework: outcomes from a preliminary study.

BACKGROUND: The recent introduction of the Professional Performance Framework by the Medical Board of Australia is intended to strengthen continuing professional development for the 100,000 or so medical practitioners in Australia. An important option within the Framework is the use of multisource feedback from patients, colleagues and self-evaluations to allow doctors to reflect on their performance and identify methods for self-improvement. The aim of this study is to explore the relationships between patient feedback, colleague feedback, and self-evaluation using the same questionnaires as used by patients and colleagues. METHODS: Feedback data for around 2000 doctors belonging to four different groups were collected through non-probability sampling from nearly 100,000 patients and 24,000 colleagues. Reliability analysis was performed using single measures intraclass coefficients, Cronbach' alpha and signal-to-noise ratios. Analysis of variance was used to identify significant differences in scores between items and sub-populations of doctors; principal component analysis involving Kaiser-Meyer-Olkin (KMO) sampling adequacy and Bartlett's test for sphericity was used to reveal components of doctor performance; and correlation analysis was used for identifying convergence between sets of scores from different sources. RESULTS: Patients rated doctors highest on respect shown and lowest on reassurance provided. Colleagues rated doctors highest on trustworthiness and lowest on ability to say 'no'. With regard to self-evaluation, doctors gave themselves lower scores on the patient questionnaire and the colleague questionnaire (10 and 12%, respectively) than they received from their patients and colleagues. There were weak but positive correlations between self-scores and scores received indicating some convergence of agreement, with doctors feeling more comfortable with self-evaluation from the perspective of patients than from colleagues. CONCLUSIONS: Supplementing patient and colleague feedback with self-evaluation may help doctors confirm for themselves areas for enhanced CPD through convergence. If self-evaluation is used, the colleague questionnaire may be sufficient, since aspects of clinical competence, management, communication and leadership as well as patient care can be addressed through colleague items. Mentoring of doctors in CPD should aim to make doctors feel more comfortable about being rated by colleagues to enhance convergence between self-scores and evaluations from the perspective of colleagues.

Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability.

BACKGROUND: Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability. Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of 'block rotations' with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation. WHAT WAS DONE: A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque's research in business. The framework's four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the 'whole of class' innovation. DISCUSSION: Roberto and Levesque's framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators. Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.

Medical students on long-term regional and rural placements: what is the financial cost to supervisors?

INTRODUCTION: Medical student education is perceived as utilising significant amounts of preceptors' time, negatively impacting on clinical productivity. Most studies have examined short-term student rotations in urban settings, limiting their generalisability to other settings and educational models. To test Worley and Kitto's hypothetical model which proposed a 'turning point' when students become financially beneficial, this study triangulated practice financial data with the perspectives of clinical supervisors before and after regional/rural longitudinal integrated community-based placements. METHODS: Gross practice financial data were compared before and during the year-long placement. Interview data pre- and post-placement were analysed by two researchers who concurred on emergent themes and categories. METHODS: This study suggested a financial 'turning point' of 1-2 months when the student became beneficial to the practice. Most preceptors (66%) perceived the longitudinal placement as financially neutral or favourable. Nineteen per cent of supervisors reported a negative financial impact, some attributing this to reduced patient throughput, inadequacy of the government teaching subsidy and/or time spent on assessment preparation. Other supervisors were unconcerned about costs, perceiving that minor financial loss was outweighed by personal satisfaction. CONCLUISONS: Senior students learning in long-term clerkships are legitimate members of regional/rural communities of practice. These students can be cost-neutral or have a small positive financial impact on the practice within a few months. Further financial impact research should include consideration of different models of supervisor teaching subsidies. The ultimate financial benefit of a model may lie in the recruitment and retention of much-needed regional and rural practitioners.

Engaging rural preceptors in new longitudinal community clerkships during workforce shortage: a qualitative study.

BACKGROUND: In keeping with its mission to produce doctors for rural and regional Australia, the University of Wollongong, Graduate School of Medicine has established an innovative model of clinical education. This includes a 12-month integrated community-based clerkship in a regional or rural setting, offering senior students longitudinal participation in a 'community of practice' with access to continuity of patient care experiences, continuity of supervision and curriculum, and individualised personal and professional development. This required developing new teaching sites, based on attracting preceptors and providing them with educational and physical infrastructure. A major challenge was severe health workforce shortages. METHODS: Before the new clerkship started, we interviewed 28 general practitioners to determine why they engaged as clerkship preceptors. Independent researchers conducted semi-structured interviews. Responses were transcribed for inductive qualitative content analysis. RESULTS: The new model motivated preceptors to engage because it enhanced their opportunities to contribute to authentic learning when compared with the perceived limitations of short-term attachments. Preceptors appreciated the significant recognition of the value of general practice teaching and the honour of major involvement in the university. They predicted that the initiative would have positive effects on general practitioner morale and improve the quality of their practice. Other themes included the doctors' commitment to their profession, 'handing on' to the next generation and helping their community to attract doctors in the future. CONCLUSIONS: Supervisors perceive that new models of clinical education offer alternative solutions to health care education, delivery and workforce. The longitudinal relationship between preceptor, student and community was seen as offering reciprocal benefits. General practitioners are committed to refining practice and ensuring generation of new members in their profession. They are motivated to engage in novel regional and rural longitudinal clinical clerkships as they perceive that they offer students an authentic learning experience and are a potential strategy to help address workforce shortages and maldistribution.

General practice education and training: past experiences, current issues and future challenges.

Reflection on past achievements and future challenges 10 years after the establishment of the Australian General Practice Training program.

Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation.

UNLABELLED: ACKGROUND:: Cervical spine fractures are common in traumatically injured patients. The halo-vest brace is a common treatment used for these fractures. We hypothesize that the use of halo-vest fixation is associated with a high incidence of dysphagia in trauma patients. METHODS: All trauma patients at our Level I Trauma Center from August 2005 to August 2007 were analyzed retrospectively via the trauma registry (N=3,702). Included were adult patients with cervical spine fractures treated with halo-vests and evaluated formally by speech-language pathologists for dysphagia and aspiration. Patients were categorized into mild, moderate, and severe dysphagia. RESULTS: Of the 3,702 patients, 369 (10%) had cervical spine fractures from blunt trauma and 56 met inclusion criteria. Of these, 19 (34%) had no evidence of swallowing dysfunction and the remaining 37 (66%) had evidence of dysphagia. Thirteen (23%) exhibited symptoms of aspiration. There were no significant differences in age, gender, Injury Severity Score, arrival Revised Trauma Score, or arrival Glasgow Coma Scale score on presentation. Dysphagia is associated with longer intensive care unit stays (p=0.019) and trends toward a longer hospital stay (p=0.083). In trauma patients with halo-vests, increasing severity of dysphagia from mild to moderate is associated with longer ventilator days (p=0.005), intensive care unit days (p=0.001), and hospital length of stay (p=0.015). CONCLUSIONS: Patients with cervical fractures treated with halo-vest fixation have a significantly high incidence of dysphagia and aspiration. Dysphagia in trauma patients treated with halo-vests for c-spine fractures is common, associated with worse outcomes, and difficult to predict. Therefore, all of these patients should be formally evaluated for dysphagia.

Health care reform--can we maintain personal continuity?

Healthcare reform is high on the political agenda, and among the critical issues that have generated significant discussion are proposals for new models of general practice organisation.

Will the NHHRC recommendations drive quality performance?

General practice is the heart of the Australian health care system, addressing the health needs of people, in their communities and in diverse locations and contexts across Australia. With over 100 million items of service claimed by general practitioners each year, even small but incremental improvements in quality have the potential to translate into population level gains in the outcomes and safety of general practice care. In recent years, Australian general practice has undertaken significant work in quality improvement, with practice accreditation to The Royal Australian College of General Practitioners standards and the Australian Primary Care Collaboratives Program being examples. Will the recommendations of the National Health and Hospitals Reform Commission (NHRC) enhance this work?

A model of clinical problem-based learning for clinical attachments in medicine.

CONTEXT: Problem-based learning (PBL) has been widely adopted in medical curricula for early-years training, but its use during clinical attachments has not been extensively explored. Objectives This study aimed to develop and evaluate a new model, 'clinical problem-based learning' (CPBL), to promote learning skills, attitudes and knowledge during clinical attachments. METHODS: The CPBL model takes the principles of PBL and applies them to learning during clinical attachments. Real patient encounters are guided by a list of broadly defined case types to ensure curriculum coverage. By discussing history taking and examination in the context of differential diagnosis and problem listing, students generate learning objectives relating to clinical skills, disease mechanisms and clinical management. These are explored through self-directed learning before the second tutorial, in which the tutor takes the role of 'expert', demonstrating how learned material translates into clinical practice. We evaluated which components contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus (Delphi process) method. RESULTS: Students found CPBL a positive learning experience. Identification of suitable cases for discussion was readily achieved, although follow-up was sometimes difficult. The tutor's level of expertise and a non-threatening learning environment, conducive to student questioning, were highly rated contributors to successful CPBL. Comments reinforced the view that CPBL is a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching. CONCLUSIONS: Clinical problem-based learning was well received in clinical placements. Key elements were the learning interval, the involvement of expert tutors and a non-threatening learning environment.

Assessing general practice knowledge base--the applied knowledge test.

The Royal Australian College of General Practitioners (RACGP) Fellowship examination assesses competence for unsupervised clinical practice anywhere in Australia through three segments, each with a unique focus. The applied knowledge test (AKT) is a written examination that tests candidates' applied clinical knowledge. Other segments assess clinical problem solving skills and ability to perform in a clinical situation. Approximately 400-500 candidates sit each administration of the RACGP examination, which is held twice yearly throughout Australia.

General practice research training: impact of the Australian Registrar Research Workshop on research skills, confidence, interest and involvement of participants, 2002-2006.

BACKGROUND: An intensive 3-day training programme, the 'Registrar Research Workshop' (RRW), has aimed to build research capacity among Australian general practice registrars since 1994. OBJECTIVES: To investigate the impact of the RRW on participants' skills, confidence, interest in research and research activity. METHODS: Cross-sectional postal survey in 2006 of five groups of registrars who participated in the annual workshop in 2002-2006 (response rate: 64%; 77 of 121). Outcome measures included research experience and skills prior to and after the workshop; impact of the workshop on capacity, confidence, attitude and interest in research; and research involvement as measured by publications and grant funding. RESULTS: Self-reported research skills increased over time for the whole group (two-way analysis of variance: P = 0.047), most significantly for registrars with little or no research experience (P < 0.001) and research project participants (P = 0.003). The impact of the workshop on capacity, confidence and interest in research was rated highly (mean 3.5-4.0 +/- 0.1 on a five-point scale). Two-thirds of the survey respondents had been research active, 34% presented their findings at conferences, 25% published in peer-reviewed journals and 31% received research funding. Eighty-four per cent of respondents indicated a high interest in undertaking research in the future. All survey respondents recommended the workshop to other registrars. CONCLUSIONS: The RRW provides a useful model for effective research training for interested general practice trainees. Such training has the potential to increase knowledge of research methods, which might augment future research activity in general practice.

Bursaries, writing grants and fellowships: a strategy to develop research capacity in primary health care.

BACKGROUND: General practitioners and other primary health care professionals are often the first point of contact for patients requiring health care. Identifying, understanding and linking current evidence to best practice can be challenging and requires at least a basic understanding of research principles and methodologies. However, not all primary health care professionals are trained in research or have research experience. With the aim of enhancing research skills and developing a research culture in primary health care, University Departments of General Practice and Rural Health have been supported since 2000 by the Australian Government funded 'Primary Health Care Research Evaluation and Development (PHCRED) Strategy'. A small grant funding scheme to support primary health care practitioners was implemented through the PHCRED program at Flinders University in South Australia between 2002 and 2005. The scheme incorporated academic mentors and three types of funding support: bursaries, writing grants and research fellowships. This article describes outcomes of the funding scheme and contributes to the debate surrounding the effectiveness of funding schemes as a means of building research capacity. METHODS: Funding recipients who had completed their research were invited to participate in a semi-structured 40-minute telephone interview. Feedback was sought on acquisition of research skills, publication outcomes, development of research capacity, confidence and interest in research, and perception of research. Data were also collected on demographics, research topics, and time needed to complete planned activities. RESULTS: The funding scheme supported 24 bursaries, 11 writing grants, and three research fellows. Nearly half (47%) of all grant recipients were allied health professionals, followed by general practitioners (21%). The majority (70%) were novice and early career researchers. Eighty-nine percent of the grant recipients were interviewed. Capacity, confidence, and level of research skills in ten core areas were generally considered to have improved as a result of the award. More than half (53%) had presented their research and 32% had published or submitted an article in a peer-reviewed journal. CONCLUSION: A small grant and mentoring scheme through a University Department can effectively enhance research skills, confidence, output, and interest in research of primary health care practitioners.

Setting directions for capacity building in primary health care: a survey of a research network.

BACKGROUND: The South Australian Research Network 'SARNet' aims to build research capacity in primary health care, as part of a national government-funded strategy to integrate research into clinical practice. Internationally, research networks have been a fundamental part of research culture change, and a variety of network models exist. The 'SARNet' model uses a whole system, multidisciplinary approach to capacity building and supports individuals and groups. We undertook a descriptive baseline survey in order to understand the background and needs of SARNet members and to tailor network activities towards those needs. METHODS: A questionnaire survey, assessing members' professional background, research experience, and interest in research development and training, was sent to all members who joined the network in its first year. The visual 'research spider' tool was used to ascertain members' experience in ten core research skills, as well as their interest in developing these skills. Individuals were asked to classify themselves into one of four categories of researchers, based on previous research experience. These self-assessment categories ranged from non-participant to academic. RESULTS: Network membership was diverse. Of the 89 survey participants, 55% were general practitioners or allied health professionals. Overall, most survey respondents indicated little to moderate experience in 7 out of the 10 skills depicted in the 'research spider'. In comparison, respondents were generally highly interested in developing their research skills in all areas. Respondents' research skills correlated significantly with their self-assessed category of research participation (Spearman rank correlation, r = 0.82, p < 0.0005). Correlations between research category and publication record (Gamma association, gamma = 0.53, p < 0.0005) or funding record (Gamma association, gamma = 0.62, p < 0.0005) supported the internal validity of the survey instrument. CONCLUSION: Literature describing evaluation of the impact of networks is scarce. Our survey questionnaire could provide a useful instrument for evaluation of both networks and capacity building initiatives. The survey including the 'research spider' tool provided valuable information about members' needs and interest in strategies to develop their research skills. Initial needs analyses as well as on-going evaluation of network activities are important to include into the business plans of research networks, in order to ensure the network's effectiveness and support of its membership.

Assessing general practice clinical decision making skills: the key features approach.

The key feature problem (KFP) is an innovative assessment format that tests clinical decision making skills by focussing on only the critical steps -- or 'key features' -- of each decision, thereby increasing the number of problems that can be answered in a 3 hour examination. It has been used successfully in The Royal Australian College of General Practitioners Examination for Fellowship and is gaining in popularity in other high stakes testing settings. This article describes how the KFP paper is designed and constructed, how the pass mark is set, and how the approach performs.

A practical guide to assessing clinical decision-making skills using the key features approach.

AIM: This paper in the series on professional assessment provides a practical guide to writing key features problems (KFPs). Key features problems test clinical decision-making skills in written or computer-based formats. They are based on the concept of critical steps or 'key features' in decision making and represent an advance on the older, less reliable patient management problem (PMP) formats. METHOD: The practical steps in writing these problems are discussed and illustrated by examples. Steps include assembling problem-writing groups, selecting a suitable clinical scenario or problem and defining its key features, writing the questions, selecting question response formats, preparing scoring keys, reviewing item quality and item banking. CONCLUSION: The KFP format provides educators with a flexible approach to testing clinical decision-making skills with demonstrated validity and reliability when constructed according to the guidelines provided.

Patients' views on the training of medical students in Australian general practice settings.

AIM: To explore patients' views on training medical students in their general practice. METHOD AND SETTING: Consenting patients attending eight urban teaching practices completing a self administered survey before and after the consultation. RESULTS: One hundred and four patients attended for appointments: 94 consented to the involvement of a medical student, 88 completed surveys before and after their consultation (response rate 85%), 80% said the main reason for consenting was to benefit the student, and 70% said they would never refuse the presence of a medical student. Student involvement was less than that consented to: only 18 (20%) patients reported that the student independently conducted any of the consultation; 52 (59%) would accept this level of involvement in the future. DISCUSSION: Patients are a willing, but potentially under used resource for training medical students in general practice. Improved collaboration with patients would provide better teaching opportunities for students at all levels.

Faculty development for problem-based learning.

Changing to a problem-based learning (PBL) curriculum represents a substantial challenge because many faculty members are unfamiliar with the process. Faculty development is a crucial component of successful curriculum change to PBL. This paper describes a logical process for designing and implementing a comprehensive faculty development programme at three main stages of change: curriculum transition, curriculum implementation and curriculum advancement. The components of each stage are discussed with reference to the literature and practice. Future advances in faculty development include harnessing the potential of complex adaptive systems theory in understanding and facilitating the change process, and incorporating the results of research, which illuminates the relationships of the PBL tutorial process to student achievement. There is a continuing need for rigorous outcome-based research and programme evaluation to define the best components and strategies for faculty development.

Building research capacity. An exploratory model of GPs' training needs and barriers to research involvement.

AIMS: To determine general practitioners' research training needs, and the barriers to involvement in research. METHOD: Semi-structured interviews with 11 GPs in rural and metropolitan South Australia, analysed using a grounded theory approach. RESULTS: General practitioners' perceptions about their research needs were limited by their own experience and focussed at an individual level. Overlapping needs and barriers emerged, categorised as: 'individual issues' (a lack of research training or experience, concepts and attitudes to research, and research interest) and 'systems issues' (funding arrangements for general practice, access to resources, opportunity for publication and the role of The Royal Australian College of General Practitioners [RACGP]). DISCUSSION: Our data provide an exploratory model that may assist in developing suitable strategies for research capacity building programs. General practitioners perceived both individual and systems solutions to building research capacity, including multifaceted interventions.