Pivoting in the pandemic: A regional tale of the rapid pivot to virtual continuing professional development for general practitioner supervisors during COVID-19.

BACKGROUND: The COVID-19 pandemic disrupted face-to-face delivery of general practitioner supervisor training in an unprecedented way. Simultaneously, the need for continuing professional development (CPD) amplified. The rapid pivot to virtual and blended learning solutions required great organisational agility, and a toolbox of solutions. OBJECTIVE: Against the backdrop of the COVID-19 restrictions on face-to-face learning, this article shares the strategies employed to achieve the pivot to virtual CPD. DISCUSSION: There was much trial and error, as well as successes and learning opportunities, as training organisations grappled with how to deliver virtual CPD during lockdowns.

How do general practitioners manage patients with cancer symptoms? A video-vignette study.

OBJECTIVES: Determine how general practitioners (GPs) manage patients with cancer symptoms. DESIGN: GPs reviewed 24 video-vignettes and case notes on patients with cancer symptoms and indicated whether they would refer the patient and/or prescribe medication, and/or undertake further investigation. According to available guidelines, all cases warranted a referral to a specialist or further investigations. SETTING: Australian primary care sector. PARTICIPANTS: 102 practising GPs participated in this study, including trainees. INTERVENTIONS: The research was part of a larger randomised controlled trial testing a referral pro forma; however, this paper reports on management decisions made throughout the study. PRIMARY AND SECONDARY OUTCOME MEASURES: This paper reports on how the participants would manage the patients depicted in each vignette. RESULTS: In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options-that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a 'prescription only' or 'referral only' option. They were less likely to manage prostate cancer with a 'prescription only', yet more likely to manage it with a 'referral with investigation'. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a 'referral only' or a 'referral with investigation'. CONCLUSIONS: Some patients may receive a delayed cancer diagnosis, even when they present with typical cancer symptoms to a GP who can access relevant diagnostic tests. TRIAL REGISTRATION NUMBER: ACTRN12611000760976.

Impact of referral letters on scheduling of hospital appointments: a randomised control trial.

BACKGROUND: Communication is essential for triage, but intervention trials to improve it are scarce. Referral Writer (RW), a referral letter software program, enables documentation of clinical data and extracts relevant patient details from clinical software. AIM: To evaluate whether specialists are more confident about scheduling appointments when they receive more information in referral letters. DESIGN AND SETTING: Single-blind, parallel-groups, controlled design with a 1:1 randomisation. Australian GPs watched video vignettes virtually. METHOD: GPs wrote referral letters after watching vignettes of patients with cancer symptoms. Letter content was scored against a benchmark. The proportions of referral letters triagable by a specialist with confidence, and in which the specialist was confident the patient had potentially life-limiting pathology were determined. Categorical outcomes were tested with χ(2) and continuous outcomes with t-tests. A random-effects logistic model assessed the influence of group randomisation (RW versus control), GP demographics, clinical specialty, and specialist referral assessor on specialist confidence in the information provided. RESULTS: The intervention (RW) group referred more patients and scored significantly higher on information relayed (mean difference 21.6 [95% confidence intervals {CI} = 20.1 to 23.2]). There was no difference in the proportion of letters for which specialists were confident they had sufficient information for appointment scheduling (RW 77.7% versus control 80.6%, P = 0.16). In the logistic model, limited agreement among specialists contributed substantially to the observed differences in appointment scheduling (P = 35% [95% CI 16% to 59%]). CONCLUSION: In isolation, referral letter templates are unlikely to improve the scheduling of specialist appointments, even when more information is relayed.

A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice.

OBJECTIVE: To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs). TRIAL DESIGN: GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1 week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems. METHODS: Setting Primary care. Participants Practising Australian GPs. Intervention A short or long hospital discharge letter enumerating patient problems. Outcome measure Number of ongoing patient problems out of 10 identified for management by the GPs. Randomisation 1:1 randomisation. Blinding (masking) Single-blind. RESULTS: Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information (p<0.001). Those who received the letter immediately identified significantly more health problems (p=0.001). GPs who received a short, delayed discharge letter were less satisfied than those who received a longer delayed letter (p=0.03); however, both groups who received the delayed letter identified a similar number of health problems. GPs who were older, who practised in an inner regional area or who offered more patient sessions per week identified fewer health problems (p values <0.01, <0.05 and <0.05, respectively). Harms Nil. CONCLUSIONS: Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed. TRIAL REGISTRATION NUMBER: ACTRN12614000403639.

Maps and arterial roads.

It can all look good on the map. The pathway seems clear. You have a system­ what can go wrong on the way from here to there? It is only when looking closely ­ or when trying to work out why you are in the wrong place ­ that the complexity becomes apparent, and the weaknesses inherent in the system obvious. The road that you planned to take is blocked by an accident, the side street which you then find as a way out is clogged by parked cars, and then everyone decides to use the bus lane to keep more lanes of traffic moving.

Balancing on the tightrope.

Balance ­ an ideal or a state that wobbles,but one we can grasp onto. When lacking,in medicine or in life, the results can be catastrophic. Omission or commissioncan upset the balance.

Motor accident insurance authority forms - a guide for GPs.

BACKGROUND: In each jurisdiction of Australia there is a system to provide appropriate compensation for persons who are injured or die as a result of a transport accident. The schemes are compulsory and usually funded via a levy on vehicle registration or compulsory insurance. The exact eligibility and structure varies greatly between states and territories. OBJECTIVE: This article highlights the important role that the general practitioner plays in an injured person's recovery, and provides an overview of the types of forms commonly requested from GPs and general guidelines for how these should be completed. DISCUSSION: In order to determine the appropriate entitlements and reasonable treatment and services an injured person requires as a result of a transport accident injury, the authority may require information from the treating GP. The use of specific forms for this information aims to efficiently facilitate the allocation of these benefits. It is important that forms are completed accurately and provide sufficient information to enable the insurer to process the claim promptly. Regardless of whether or not the patient can claim insurance, the GP plays a pivotal role in any injured person's recovery and return to work.

Opportunity cost.

Opportunity cost and trade-off - similar concepts with slightly different meanings and definitions in different fields - are concepts that we were all probably first exposed to as a toddler. For most women however, opportunity cost and trade-off is a part of their daily lives as they try to balance their needs, including their health needs, with the demands of their families, careers and never-ending 'to do' lists.

Gaps, holes and change.

The start of a new year can be a time for reflection of the past and consideration of the future. Whether or not you are a fan of new year resolutions, there is usually something that you want to change. This issue of Australian Family Physician considers gaps in practice. Sometimes as general practitioners we know that there is a gap; sometimes our patients know that there is a gap; and sometimes there is a gap but no-one recognises that one exists. Sometimes we go along thinking that what we are doing is evidence based, and then get an unpleasant surprise when asked to justify 'what we always do'!

Psychosexual problems in general practice: measuring consultation competence using two different measures.

BACKGROUND: Psychosexual problems are a common presentation in general practice. Given that the cornerstone of assessment is excellent consultations skills, it may be assumed that general practitioners (GPs) will perform skilfully for such presentations. AIM: To determine if there is a significant difference in consultation skills assessed using a generic test of consultation performance compared to one which has been specifically developed for experts in psychosexual care, albeit modified for general practice consultations. METHODS: Six GPs were video recorded consulting six standardised patients at their respective practices. Two assessors independently rated the consultation performance using the Leicester Assessment Package (LAP), a generic tool to assess GP consultation performance. Four sexologists, blind to the review by the LAP assessors, assessed the same consultations deploying the Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) framework. The PLISSIT is routinely used to teach health professionals communication skills when consulting people with psychosexual problems. RESULTS: Thirty-four consultations were successfully recorded. The mean duration of consultations was 12 minutes and 10 seconds (range 7 m. 54 s. to 16 m. 54 s.). Three GPs differed significantly in core competencies as measured by the LAP. Similarly, three GPs differed in competencies as measured by the PLISSIT. There were significant differences in mean LAP scores and PLISSIT scores observed for different doctors. Mean LAP scores varied by actor-scenario after adjusting for doctor clustering, whereas PLISSIT scoring did not vary significantly by actor-scenario in this small study with limited power. There was no evidence that mean LAP scores were associated with PLISSIT scores. CONCLUSIONS: Two measures of consultation competence revealed different outcomes when applied to the same consultations. We found evidence that general practitioners vary significantly on different measures of consultation competence when consulting patients with psychosexual problems in the context of a cancer diagnosis.

Is it all in the act?

Struggling to breathe is one of the most distressing symptoms to have, or to witness. Treating acute shortness of breath is rewarding for both the patient and the doctor. The patient often takes at least the initial dose of medication under your (or your practice nurse's) supervision. You know it was taken and taken correctly.

From the mind to the hands.

There are times when the unseen becomes seen. Two recent events highlighted this for me. The first was an evening telephone call about a 10 month old with a rash, asking: 'Could be measles?' The second was a patient asking if I was worried about her blood sugar levels (BSL), which had become elevated in the past month. Common general practice questions; however both made me stop, consider what had happened in the mind, and the process of arriving at the answer to the questions posed.

In the eye of the beholder. Risk perception.

Risk is an individual business. Some people see skydiving as safe, thrilling and enjoyable; I see it as the stuff of nightmares! What about plane versus car travel? Is it more risky driving to the airport or getting on the plane? What do the figures show? What does our gut say? Why do we have these ideas? Part of the answer to these questions lies in what we hear about.

Investigating the impact of extraneous distractions on consultations in general practice: lessons learned.

BACKGROUND: Extraneous distractions may influence the flow of general practice consultations. This study piloted a methodology to examine the impact of interrupting general practitioners (GPs) while consulting actor-patients. METHODS: Six GPs were video recorded consulting six actor-patients each presenting a different clinical scenario in a simulated surgery. Five cases presented red flag cancer symptoms. Half the consultations were interrupted. Two independent assessors, blinded to the occurrence of interruptions, assessed consultation performance using the Leicester Assessment Package (LAP) for clinical competence. RESULTS: 24 of 36 consultations were video recorded with sufficient audio-visual clarity to allow scoring. The association between LAP score and three variables could be studied: a variety of interruptions, different GPs and various scenarios. Agreement between assessors on GP performance was poor and showed an increased bias with increasing LAP score. Despite this, the interruption did not significantly impact on assessor LAP scores (Mean difference: 0.22, P = 0.83) even after controlling for assessor, different GPs and scenarios. CONCLUSION: Extraneous distractions had no impact on GP performance in this underpowered pilot study, a conclusion which needs to be confirmed in a larger study. However several important lessons were learned. Recorded actor-patient clinical sessions are logistically challenging. GPs whose skills were not previously assessed were working in unfamiliar surroundings dealing with relatively straight forward diagnostic challenges and may have anticipated the interruptions. In a redesign of this experiment it may be possible to eliminate some of these limitations.