The never ending road: improving, adapting and refining a needs-based model to estimate future general practitioner requirements in two Australian states.

Background: Health workforce planning models have been developed to estimate the future health workforce requirements for a population whom they serve and have been used to inform policy decisions. Objectives: To adapt and further develop a need-based GP workforce simulation model to incorporate current and estimated geographic distribution of patients and GPs. Methods: A need-based simulation model that estimates the supply of GPs and levels of services required in South Australia (SA) was adapted and applied to the Western Australian (WA) workforce. The main outcome measure was the differences in the number of full-time equivalent (FTE) GPs supplied and required from 2013 to 2033. Results: The base scenario estimated a shortage of GPs in WA from 2019 onwards with a shortage of 493 FTE GPs in 2033, while for SA, estimates showed an oversupply over the projection period. The WA urban and rural models estimated an urban shortage of GPs over this period. A reduced international medical graduate recruitment scenario resulted in estimated shortfalls of GPs by 2033 for WA and SA. The WA-specific scenarios of lower population projections and registrar work value resulted in a reduced shortage of FTE GPs in 2033, while unfilled training places increased the shortfall of FTE GPs in 2033. Conclusions: The simulation model incorporates contextual differences to its structure that allows within and cross jurisdictional comparisons of workforce estimations. It also provides greater insights into the drivers of supply and demand and the impact of changes in workforce policy, promoting more informed decision-making.

Assessment of diagnostic skills in specialist examinations should include lessons learnt from misdiagnosis.

BACKGROUND: Poor authenticity in high stake clinical exams adversely effects validity. We propose including known misleading diagnostic factors and contextual biases in the assessment of diagnostic skills amongst advanced specialty trainees. We hypothesise that this strategy offers a more realistic and critical assessment of diagnostic skill than strategies in which candidates are presented with directive, bias free information, allowing for assumptions which cannot be made in real life. METHODS: Eleven patient based practice clinical exam stations were presented to nine advanced ophthalmology trainees. Four patients had a history of misdiagnosis or near misdiagnosis of key ophthalmic findings, presumed to result from identifiable biases and misleading information. In those four stations, candidates were presented with authentic, file based information and were asked authentic questions, similar to those with which the patients presented. If the candidates were unsuccessful in identifying key findings, the questions were converted into directive questions about the same key findings (i.e. "examine the patient's eyelids, what is your diagnosis?"), and the candidates re-assessed the patient and re-answered. RESULTS: Ninety-eight doctor-patient encounters took place. Of those, 35 encounters were analysed for the purpose of this study. In 63% of those encounters, key findings were missed when the question included authentic biases or misleading background information, but rephrasing the question to a directive exam format led to their correct identification (Fail converted to pass). Key findings were detected despite contextual biases or misleading background information in only 23% of encounters. In 14% the findings were missed with either question phrasing. CONCLUSIONS: Presentation authentic questions provide a more realistic and less forgiving measure of diagnostic skills than directive exam questions. Given the prevalence of diagnostic errors and their importance to patient outcomes, known mechanisms contributing to diagnostic errors should be used as one of the assessment tools of advanced speciality trainees.

Promoting clinical reasoning in general practice trainees: role of the clinical teacher.

BACKGROUND: Clinical reasoning requires knowledge, cognition and metacognition, and is contextually bound. Clinical teachers can and should play a key role in explicitly promoting clinical reasoning. CONTEXT: The aim of this article is to relate the clinical reasoning literature to the general practice or family medicine context, and to provide clinical teachers with strategies to promote clinical reasoning. INNOVATION: It is important that the clinical teacher teaches trainees the specific skills sets of the expert general practitioner (e.g. synthesising skills, recognising prototypes, focusing on cues and clues, using community resources and dealing with uncertainty) in order to promote clinical reasoning in the context of general practice or family medicine. Clinical teachers need to understand their own reasoning processes as well as be able to convey that knowledge to their trainees. They also need to understand the developmental stages of clinical reasoning and be able to nurture each trainee's own expertise. Strategies for facilitating effective clinical reasoning in trainees include adequate exposure to patients, offering the trainees opportunity for reflection and feedback, and coaching on the techniques of reasoning in the general practice context. IMPLICATIONS: The journey to expertise in clinical reasoning is unique to each clinician, with different skills developing at different rates, depending on content, context and past experience. Doctors enter into general practice training with the building blocks of biomedical and clinical knowledge and a desire to learn how to be a general practitioner. Clinical teachers are integral in the process of helping trainees learn how to 'think like a general practitioner'.

Lessons from the past--historical trends in the RACGP examination.

Assessment within any medical specialty college is often an area that elicits deep feelings within the medical community. The speciality of general practice is no exception, and there are a number of deeply held and widespread beliefs about The Royal Australian College of General Practitioners (RACGP) Fellowship examination. This article seeks to publish historical data from past RACGP Fellowship examinations. It is anticipated that readers with an interest in past, present and future trends will find this information useful, and it is intended that the information contained in the article will be used to inform the many debates which focus on the RACGP Fellowship examination.

Competence and the quality framework.

BACKGROUND: The quality framework developed by The Royal Australian College of General Practitioners is described by Booth in this issue of Australian Family Physician. This article applies the framework to the 'competence' domain. OBJECTIVE: This article explores the key role of competence in the delivery of quality health care. DISCUSSION: Competence is often defined in terms of the individual practitioner and there are various ways to assess attainment and maintenance of clinical competence. Professional competence requires constant attention and redevelopment in a changing clinical environment. Competence in general practice also means an emphasis on teamwork and working in teams requires specific skills sets and a systems approach. Nationally defined competencies impact at the local level in the delivery of services and it is important to be aware of that impact and ensure that standards of high quality health care are maintained and delivered.

The RACGP Examination--changes from 1999-2004.

Promoting and maintaining the quality and standards of Australian general practice on behalf of the profession and the Australian community is The Royal Australian College of General Practitioners' central activity. An important part of this process is assessment of doctors wishing to attain Fellowship of the RACGP. For general practice registrars, the summative assessment process is the college examination. This article presents details of the assessment process, outlines changes in the RACGP Examination, and publishes its outcomes. This is the first in a series of three articles focussing on changes in the RACGP Examination, its candidature, analysis of results, and plans for future development.

Practice based assessment.

BACKGROUND: Practice based assessment (PBA) was designed to suit the needs of doctors eligible to sit The Royal Australian College of General Practitioners Fellowship (FRACGP) exam via the practice eligible route. A pilot program of the PBA was undertaken in 2000. As a result of recommendations by candidates and examiners and ongoing literature review, a number of changes have been made, but the basic structure of the assessment process remains. OBJECTIVE: This article describes the components of the PBA route to the FRACGP and discuss how candidates can prepare effectively for their assessment. DISCUSSION: The PBA involves five components: an enrolment submission including details of general practice experience curriculum vitae and details of continuing professional development; a professional portfolio including evidence of CPR proficiency, a practice profile and a list of 25 professional peers who have shared the care of patients; videotape of 90 consultations; an examiner clinical visit; and a 20 question viva.

Rural secondary school students living in a small community: their attitudes, beliefs and perceptions towards general practice.

OBJECTIVE: To study the attitudes and beliefs towards general practice of rural secondary school students, in particular, their perception of the barriers to the effective delivery of primary health care. SETTING: Students attending a government-funded secondary school in a rural community of less than 4000 people. SUBJECTS: 250 students in years 7-12 were surveyed, with 177 (71%) replying, 45% of these being male. DESIGN: Cross-sectional, self-administered questionnaire survey. RESULTS: The study found that most students value general practitioners (GPs) as valuable sources of health care, feel they have reasonable access to care and in most instances appear to attend appropriately for their health problems. Most felt their doctor would be an empathetic listener, would provide sufficient time to provide effective care and communicated in a language they could understand. Confidentiality issues were considered important, especially by females. CONCLUSION: Although students have very positive attitudes about general practice, the findings could be used to improve a number of GP services for young people in small rural communities. This is particularly so for presentations which require a high degree of confidentiality and skillful counselling, such as psychological problems and risk-taking behaviours.