Early-career general practitioners' perceptions of the utility of vocational training for subsequent independent practice.

PURPOSE: To evaluate Australian early-career general practitioners' perceptions of the utility of their prior vocational training in preparing them for independent specialist practice. We hypothesised that in-practice teaching would be perceived as more useful than formal education delivered by Regional Training Organisations (RTOs). METHODS AND MATERIALS: A cross-sectional questionnaire-based study of early-career general practitioners (RTO 'alumni'). The outcomes were Likert scale ratings of alumni's perceived impact of RTO education versus in-practice training on their preparedness for independent practice. Ratings were compared using Wilcoxon signed-rank tests. Multivariable linear regression was used to establish alumni characteristics associated with perceptions of utility of in-practice versus RTO-delivered education. RESULTS: Three hundred and fifty-four alumni responded (response rate 28%). In-practice training was rated statistically significantly higher than RTO education for minor procedural skills, teaching skills, professional responsibilities, tolerating clinical uncertainty, and preparing for managing child and adolescent health, aged care, chronic disease, multi-morbidity and mental health. RTO education rated higher than in-practice training for practising evidence-based medicine and Aboriginal and Torres Strait Islander health. For a number of further areas, there was no statistically significant difference in alumni ratings of utility. CONCLUSIONS: In-practice or RTO-led teaching was perceived as more useful for some components of independent practice, whilst for others there was no significant difference. The findings support recognition of the individual educational components of a blended education/training structure.

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 finding 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.

Remodelling general practice training: Tension and innovation.

BACKGROUND AND OBJECTIVES: The transfer of general practice training in Australia to the two general practice colleges is an opportunity for change in the model of training. The dialectical theory of institutional change suggests that change occurs where organisational structures of training are in tension with the needs of those delivering training, and effective change arises from innovation within these tension points. These tensions have also been faced by general practice training organisations internationally, where solutions have also been crafted. By exploring training tensions and responses to these, the aim of this study was to inform the remodelling of general practice training in Australia. METHOD: Senior educators and stakeholder representatives in Australia and internationally were interviewed to identify tensions in training delivery and innovative responses to these. An interpretative qualitative analysis was undertaken. RESULTS: Eight key tensions and associated innovative responses were identified. DISCUSSION: Drawing from the findings, this article provides recommendations for remodelling general practice training in Australia.

International medical graduates and general practice training: How do educational leaders facilitate the transition from new migrant to local family doctor?

Objectives: To document medical educators' experience and initiatives in training international medical graduates (IMGs) to become general practitioners (GP). Design: Qualitative social-constructivist emergent design with descriptive and interpretive analyses. Setting: GP vocational training in Australia, Canada, Ireland, New Zealand, the Netherlands, and UK. Participants: Twenty-eight leaders of GP training. Intervention: Data collected from public documents, published literature and 27 semi-structured interviews. Main outcome measures: Tensions in training and innovations in response to these tensions. Results: Medical educators identified tension in teaching IMGs as it could be different to teaching domestic graduates in any or all aspects of a training program. They felt an ethical responsibility to support IMGs to provide quality health care in their adopted country but faced multiple challenges to achieve this. They described initiatives to address these throughout GP training. Conclusions: IMG's differing educational needs will benefit from flexible individualized adaptation of training programs.

General practitioner trainees' in-consultation generation of clinical questions for later answering: prevalence and associations.

Background: As well as generating patient-specific questions, patient consultations are a rich source of questions relating to clinicians' need to acquire or maintain wider clinical knowledge. This is especially so for GP trainees. Objectives: To establish the prevalence and associations of GP trainees' generation of 'learning goals' (LGs: questions generated during clinical consultations for intended post-consultation answering). Also, to characterize the type of learning goals generated. Methods: A cross-sectional analysis (2010-15) of an ongoing cohort study of Australian GP trainees' consultations. Once each 6-month training term, trainees record detailed data of 60 consecutive consultations. The primary outcome was generation of an LG. Analysis was at the level of individual problem/diagnosis managed. The secondary outcome was the problems/diagnoses to which the LGs related. Results: One thousand one hundred and twenty-four trainees contributed data for 154746 consultations including 222307 problems/diagnoses. LGs were generated for 16.6% [95% confidence intervals (CI) = 16.4-16.7] of problems/diagnoses, in 22.1% (95% CI = 21.9-22.3%) of consultations. Associations of LGs included patient factors: younger age and having seen the trainee previously; trainee factors: earlier training stage, being overseas-trained and the trainee's training organization; consultation factors: longer duration, addressing a chronic disease, referring the patient, organizing follow-up, organizing investigations and accessing in-consultation information. LGs were commonly generated for skin (12.9% of all learning goals), musculoskeletal (12.7%) and respiratory (8.7%) problems. LGs were generated for 31.8% of male genital, 27.0% of neurological and 23.3% of eye problems. Conclusion: Australian GP trainees frequently generate questions in-consultation to be pursued post-consultation. Prevalence, 'complexity' and familiarity of clinical topic area influenced LG generation.

Responding to registrars' in-consultation calls for assistance: Practical implications from the ReCeNT project.

BACKGROUND: General practice registrars in Australia are expected to identify and address their knowledge or skills gaps during consultations. The content and frequency of registrars seeking assistance and the factors that influence this have been studied for 84,723 consultations. Term 1 registrars asked their supervisor for help in 11.0% of consultations, but by term 4 this reduced to 1.2% of consultations. Assistance was most often for skin or musculoskeletal conditions, and more often about management than diagnosis. OBJECTIVE: This article discusses the implications of this information for Australian general practice training. DISCUSSION: Registrars asked their supervisors for assistance despite having ready access to electronic information. Practices can anticipate supervisor interruptions approximately every tenth registrar consultation. The greater input required by registrars from supervisors earlier in training should be acknowledged by more flexible standards and payments to practices. A priority for general practice supervisor professional development is how to teach the management of complex patients, dermatology and musculoskeletal medicine.

Educating registrars in your practice.

BACKGROUND: Postgraduate general practice training is an apprenticeship of learning to be a general practitioner by working as a general practitioner under supervision. During this apprenticeship, registrars learn the art, craft and ethics of their vocation, and how to apply clinical knowledge and skills in different contexts. OBJECTIVE: This article summarises how registrars learn, and the role of general practice supervisors and training practices in supporting their education. DISCUSSION: General practice supervisors form educational alliances with registrars that provide the foundation for deep and broad learning. Overseeing patient safety requires supervisors to respond to registrars' queries and monitor them proactively. Registrars learn best in practices that include them in all their work and share their expertise. Specific issues raised by teams of part-time super-visors, and by rural and remote practice, are discussed. Finally, teaching practices are recommended to seek and implement feedback from registrars.

Towards an educational continuing professional development (EdCPD) curriculum for Australian general practice supervisors.

BACKGROUND: Within the apprenticeship model of general practice training, the majority of teaching and learning occurs in the practice under the guidance of the general practice supervisor. One of the foundations of a high-quality general practice training program is the delivery of relevant, evidence-based educational continuing professional development (EdCPD) for general practice supervisors. Despite The Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) standards requiring EdCPD, there is currently no standardised educational curriculum for Australian general practice supervisors. There are a number of emerging themes with significant implications for future general practice supervisor EdCPD. These include clinical supervision and structural issues, capacity constraints, and emerging educational issues. OBJECTIVE: We propose the development of a core curriculum for general practice supervisors that is competency-based and evidence-based, and reflects the changing landscape of Australian general practice training. DISCUSSION: A national general practice supervisor core curriculum would provide standardisation, encourage collaboration, allow for regional adaptation, focus on developing competencies and require rigorous evaluation.

GP trainees' in-consultation information-seeking: associations with human, paper and electronic sources.

BACKGROUND: Answering clinical questions arising from patient care can improve that care and offers an opportunity for adult learning. It is also a vital component in practising evidence-based medicine. GPs' sources of in-consultation information can be human or non-human (either hard copy or electronic). OBJECTIVES: To establish the prevalence and associations of GP trainees' in-consultation information-seeking, and to establish the prevalence of use of different sources of information (human, hard copy and electronic) and the associations of choosing particular sources. METHODS: A cross-sectional analysis of data (2010-13) from an ongoing cohort study of Australian GP trainees' consultations. Once each 6-month training term, trainees record detailed data of 60 consecutive consultations. The primary outcome was whether the trainee sought in-consultation information for a problem/diagnosis. Secondary outcomes were whether information-seeking was from a human (GP, other specialist or other health professional) or from a non-human source (electronic or hard copy), and whether a non-human source was electronic or hard copy. RESULTS: Six hundred forty-five trainees (response rate 94.3%) contributed data for 84,723 consultations including 131,583 problems/diagnoses. In-consultation information was sought for 15.4% (95% confidence interval=15.3-15.6) of problems/diagnoses. Sources were: GP in 6.9% of problems/diagnoses, other specialists 0.9%, other health professionals 0.6%, electronic sources 6.5% and hard-copy sources 1.5%. Associations of information-seeking included younger patient age, trainee full-time status and earlier training stage, longer consultation duration, referring the patient, organizing follow-up and generating learning goals. Associations of choosing human information sources (over non-human sources) were similar, but also included the trainee's training organization. Associations of electronic rather than hard-copy information-seeking included the trainee being younger, the training organization and information-seeking for management rather than diagnosis. CONCLUSION: Trainee information-seeking is mainly from GP colleagues and electronic sources. Human information-sources are preferentially sought for more complex problems, even by these early-career GPs who have trained in the 'internet era'.

In-consultation information and advice-seeking by Australian GP trainees from GP trainers - a cross-sectional analysis.

INTRODUCTION: The apprenticeship model of general practice (GP) training is based on appropriate supervision. A central component of supervision - in-consultation information-seeking of GP trainees from their trainer - has not been documented. We aimed to establish the prevalence, characteristics and associations (trainee, practice, patient and consultation) of this information-seeking. METHODS: Australian trainees recorded demographic, clinical and educational details of 60 consecutive consultations in each GP term of their training, including the rate and nature of information-seeking. RESULTS: Six-hundred and forty-five trainees contributed data for 1426 trainee-rounds, 84 723 consultations and 131 583 problems. Information was sought from the trainer for 9130 (6.9% (95% CI 6.8-7.1)) of all problems encountered (and in 7833 (9.2% (95% CI 9.0-9.4)) of consultations): 11.7% (95% CI 11.0- 12.4) were for diagnosis, 53.1% (95% CI 52.1-54.2) for management and 35.2% (95% CI 34.2-36.2) for both diagnosis and management. Assistance was sought most commonly for skin problems (20.0%) and musculoskeletal problems (12.6%). Significant adjusted associations of information-seeking included patient age; male patient gender; earlier training term; trainee being younger and female; trainee's training organisation; longer consultation; and trainee generation of learning goals. DISCUSSION: Our findings have implications for trainer workload and professional development, patient care and trainee education and training.

Supervisor continuity or co-location: which matters in residency education? Findings from a qualitative study of remote supervisor family physicians in Australia and Canada.

PURPOSE: Changes to health care systems and working hours have fragmented residents' clinical experiences with potentially negative effects on their development as professionals. Investigation of off-site supervision, which has been implemented in isolated rural practice, could reveal important but less overt components of residency education. METHOD: Insights from sociocultural learning theory and work-based learning provided a theoretical framework. In 2011-2012, 16 family physicians in Australia and Canada were asked in-depth how they remotely supervised residents' work and learning, and for their reflections on this experience. The verbatim interview transcripts and researchers' memos formed the data set. Template analysis produced a description and interpretation of remote supervision. RESULTS: Thirteen Australian family physicians from five states and one territory, and three Canadians from one province, participated. The main themes were how remoteness changed the dynamics of care and supervision; the importance of ongoing, holistic, nonhierarchical, supportive supervisory relationships; and that residents learned "clinical courage" through responsibility for patients' care over time. Distance required supervisors to articulate and pass on their expertise to residents but made monitoring difficult. Supervisory continuity encouraged residents to build on past experiences and confront deficiencies. CONCLUSIONS: Remote supervision enabled residents to develop as clinicians and professionals. This questions the supremacy of co-location as an organizing principle for residency education. Future specialists may benefit from programs that give them ongoing and increasing responsibility for a group of patients and supportive continuity of supervision as residents.

Physical isolation with virtual support: Registrars' learning via remote supervision.

PURPOSE: Changing the current geographical maldistribution of the medical workforce is important for global health. Research regarding programs that train doctors for work with disadvantaged, rural populations is needed. This paper explores one approach of remote supervision of registrars in isolated rural practice. Researching how learning occurs without on-site supervision may also reveal other key elements of postgraduate education. METHODS: Thematic analysis of in-depth interviews exploring 11 respondents' experiences of learning via remote supervision. RESULTS: Remote supervision created distinctive learning environments. Respondents' attributes interacted with external supports to influence whether and how their learning was promoted or impeded. Registrars with clinical and/or life experience, who were insightful and motivated to direct their learning, turned the challenges of isolated practice into opportunities that accelerated their professional development. DISCUSSION: Remote supervision was not necessarily problematic but instead provided rich learning for doctors training in and for the context where they were needed. Registrars learnt through clinical responsibility for defined populations and longitudinal, supportive supervisory relationships. Responsibility and continuity may be as important as supervisory proximity for experienced registrars.

Functional consequences of age-related morphologic changes to pyramidal neurons of the rhesus monkey prefrontal cortex.

Layer 3 (L3) pyramidal neurons in the lateral prefrontal cortex (LPFC) of rhesus monkeys exhibit dendritic regression, spine loss and increased action potential (AP) firing rates during normal aging. The relationship between these structural and functional alterations, if any, is unknown. To address this issue, morphological and electrophysiological properties of L3 LPFC pyramidal neurons from young and aged rhesus monkeys were characterized using in vitro whole-cell patch-clamp recordings and high-resolution digital reconstruction of neurons. Consistent with our previous studies, aged neurons exhibited significantly reduced dendritic arbor length and spine density, as well as increased input resistance and firing rates. Computational models using the digital reconstructions with Hodgkin-Huxley and AMPA channels allowed us to assess relationships between demonstrated age-related changes and to predict physiological changes that have not yet been tested empirically. For example, the models predict that in both backpropagating APs and excitatory postsynaptic currents (EPSCs), attenuation is lower in aged versus young neurons. Importantly, when identical densities of passive parameters and voltage- and calcium-gated conductances were used in young and aged model neurons, neither input resistance nor firing rates differed between the two age groups. Tuning passive parameters for each model predicted significantly higher membrane resistance (R m ) in aged versus young neurons. This R m increase alone did not account for increased firing rates in aged models, but coupling these R m values with subtle differences in morphology and membrane capacitance did. The predicted differences in passive parameters (or parameters with similar effects) are mathematically plausible, but must be tested empirically.

GP supervisors assessing GP registrars ­ theory and practice.

BACKGROUND: General practice supervisors are increasingly being expected to assess their registrars. OBJECTIVE: In this article we explore the issues this raises for supervisors, and discuss the literature, which suggests that global assessments are the most accurate and feasible. DISCUSSION: We suggest the following guidelines for supervisors: inform registrars at the beginning of the term about how and when they will be assessed; be clear that the aim is to decide if the registrars' practice is safe for patients and appropriate for their stage of training; ob-serve registrars at work; make an initial judgement of registrars' performance; test the initial judgement on performance applying qualitative research methods to improve trustworthiness and reduce potential biases; use the working diagnosis of registrar performance to guide the level of support and clinical oversight needed and flag registrars who require further assessment by educational organisations for remediation decisions.

Twelve tips on how to set up postgraduate training via remote clinical supervision.

Doctors-in-training can now be supervised remotely by specialist clinicians using information and communication technology. This provides an intermediate stage of professional development between on-site supervision and independent medical practice. Remote supervision could increase training capacity, particularly in underserved areas and ensure doctors are willing and able to practice where they are needed once qualified. Remotely supervised doctors learn via virtual autonomy in clinical decision making and working at the limits of their abilities. It suits experienced registrars with resilience, insight into their strengths and weaknesses, capacity to self-monitor and correct, and willingness to seek help. These doctors benefit from remote supervisors who facilitate their learning, monitor their well-being, and support them holistically. Educational organisations need to oversee remote placements and match the right registrar, to the right placement with the right supervisor. We outline in our twelve tips how to set up remote supervision in order to maximise the educational benefits and minimise the risks.

General practitioners as supervisors in postgraduate clinical education: an integrative review.

CONTEXT: General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory. METHODS: We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings. RESULTS: Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned 'know that' into 'know how'. CONCLUSIONS: General practice must be expert in ensuring patients are well cared for 'by proxy' and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved.