Emergency department referral patterns of Australian general practitioner registrars: a cross-sectional analysis of prevalence, nature and associations.

Objective Limited international evidence suggests general practice registrars' emergency department (ED) referral rates exceed those of established general practitioners (GPs). The aim of the present study was to fill an evidence gap by establishing the prevalence, nature and associations of Australian GP registrar ED referrals. Methods A cross-sectional analysis was performed of the Registrar Clinical Encounters in Training (ReCEnT) cohort study of GP registrars' consultation experiences, between 2010 and 2015. The outcome factor in logistic regression analysis was referral to an ED. Independent variables included patient-level, registrar-level, practice-level and consultation-level factors. Results In all, 1161 GP registrars (response rate 95.5%) contributed data from 166966 consultations, comprising 258381 individual problems. Based on responses, 0.5% of problems resulted in ED referral, of which nearly 25% comprised chest pain, abdominal pain and fractures. Significant (P < 0.05) associations of ED referral included patient age <15 and >34 years, the patient being new to the registrar, one particular regional training provider (RTP), in-consultation information or assistance being sought and learning goals being generated. Outer regional-, remote- or very remote-based registrars made significantly fewer ED referrals than more urban registrars. Of the problems referred to the ED, 45.5% involved the seeking of in-consultation information or assistance, predominantly from supervisors. Conclusions Registrars' ED referral rates are nearly twice those of established GPs. The findings of the present study suggest acute illnesses or injuries present registrars with clinical challenges and real learning opportunities, and highlight the importance of continuity of care, even for acute presentations. What is known about the topic? A GP's decision concerning continued community- versus hospital-based management of acute presentations demands careful consideration of a suite of factors, including implications for patient care and resource expenditure. General practice vocational training is a critical period for the development of GP registrars' long-term patterns of practice. Although limited international evidence suggests GP registrars and early career GPs refer patients to the ED at a higher rate than their more experienced peers, these studies involved small subject numbers and did not investigate associations of registrars making an ED referral. Relevant Australian studies focusing on GP registrars' ED referral patterns are lacking. What does this paper add? The present ongoing cohort study is the first to establish the patterns of ED referrals made by Australian GP registrars, encompassing five general practice RTPs across five states, with participating registrars practising in urban, rural, remote and very remote practices. Several significant associations were found with GP registrars making ED referrals, including patient age, continuity of care, the registrar's RTP, assistance sought by the registrar and rurality of the registrar's practice. What are the implications for practitioners? The higher likelihood of GP registrars seeing acute presentations than their more established practice colleagues, coupled with a demonstrated association of registrars seeking in-consultation assistance for such presentations, highlights the importance of GP supervisor accessibility in facilitating ED referral appropriateness and in the development of registrars' safe clinical practice.

General practice registrars' clinical exposure to dermatological procedures during general practice training: a cross-sectional analysis.

Australian general practitioners (GPs) commonly manage dermatological conditions requiring procedures. GP registrars have limited pre-vocational training exposure to dermatology and find skin problems challenging. We aimed to establish the prevalence, nature and associations of GP registrars' performance of skin procedures. We conducted a cross-sectional analysis from the Registrar Clinical Encounters in Training cohort study. Multivariable logistic regression was used to establish associations of our outcome (skin procedures, both including and excluding cryotherapy). Independent variables included patient and doctor demographics, diagnoses/problems managed and registrars' recourse to in-consultation assistance/information. A total of 1161 registrars provided data on 166,988 consultations, recording 2927 skin procedures (16.7% of all procedures; performed in 1.7% of consultations). Cryotherapy, excision, punch biopsy and shave biopsy were most common. More complex procedures were performed infrequently. Significant associations of performing procedures included rural/remote location (compared to major city), male patients, patient age 65+ (compared to age 15-34) and registrars seeking in-consultation information/assistance. Skin procedures were less likely for Aboriginal patients or those from non-English-speaking backgrounds. For non-cryotherapy procedures, rurality was not significantly associated, but significant differences were found between training regions. In summary, GP registrars perform fewer dermatological procedures compared to established GPs. Findings will inform GP vocational training in skin procedures.

Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis.

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.

Quality assessment of systematic reviews of vitamin D, cognition and dementia.

BACKGROUND: There is conflicting evidence regarding the association of vitamin D with cognition performance and dementia.AimsWe aimed to summarise the evidence on the association of vitamin D with cognitive performance, dementia and Alzheimer disease through a qualitative assessment of available systematic reviews and meta-analyses. METHOD: We conducted an overview of the systematic reviews of all study types with or without meta-analyses on vitamin D and either Alzheimer disease, dementia or cognitive performance up to June 2017. RESULTS: Eleven systematic reviews were identified, nine of which were meta-analyses with substantial heterogeneity, differing statistical methods, variable methodological quality and quality of data abstraction. A Measurement Tool to Assess Systematic Reviews checklist scores ranged from 4 to 10 out of 11, with seven reviews of 'moderate' and four of 'high' methodological quality. Out of six meta-analyses on the association between low serum concentration of 25-hydroxyvitamin D and risk of dementia, five showed a positive association. Results of meta-analyses on the association between low serum concentration of 25-hydroxyvitamin D and memory function tests showed conflicting results. CONCLUSIONS: This systematic evaluation of available systematic reviews provided a clearer understanding of the potential link between low serum vitamin D concentrations and dementia. This evaluation also showed that the quality of the available evidence is not optimal because of both the low methodological quality of the reviews and low quality of the original studies. Interpretation of these systematic reviews should therefore be made with care.Declaration of interestNone.

Referrals to dietitians/nutritionists: A cross-sectional analysis of Australian GP registrars' clinical practice.

AIM: The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals. METHODS: This was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six-month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010-2015). Independent variables were related to registrar, patient, practice and consultation. RESULTS: A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23-0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement. CONCLUSIONS: Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients' complex care needs.

Maintaining capacity for in-practice teaching and supervision of students and general practice trainees: a cross-sectional study of early career general practitioners.

Objectives Expanding learner cohorts of medical students and general practitioner (GP) vocational trainees and the impending retirement of the 'baby boomer' GP cohort threaten the teaching and supervisory capacity of the Australian GP workforce. Engaging newly qualified GPs is essential to sustaining this workforce training capacity. The aim of the present study was to establish the prevalence and associations of in-practice clinical teaching and supervision in early career GPs. Methods The present study was a cross-sectional questionnaire-based study of recent (within 5 years) alumni of three of Australia's 17 regional general practice training programs. The outcome factor was whether the alumnus taught or supervised medical students, GP registrars or other learners in their current practice. Logistic regression analysis was used to establish associations of teaching and supervision with independent variables comprising alumnus demographics, current practice characteristics and vocational training experiences. Results In all, 230 alumni returned questionnaires (response rate 37.4%). Of currently practising alumni, 52.4% (95% confidence interval (CI) 45.6-59.0%) reported current teaching or supervisory activities. Factors significantly (P<0.05) associated with alumni currently undertaking in-practice clinical teaching and supervision were: Australian medical graduation (odds ratio (OR) for international graduates 0.36; 95% CI 0.14-0.92), working in a regional or remote area (OR 2.75; 95% CI 1.24-6.11) and currently undertaking nursing home visits, home visits or after-hours work (OR 2.01; CI 1.02-3.94). Conclusions Rural-urban and country-of-graduation differences in the engagement of early career GPs in practice-based apprenticeship-like teaching or training should inform strategies to maintain workforce training capacity. What is known about the topic? Projected changes in the demand for and supply of clinical teaching and supervision within Australian general practice will require greater uptake of teaching and supervision by recently qualified GPs to ensure sustainability of this teaching model. Although interest in and undertaking of teaching roles have been documented for GP or family medicine trainees, studies investigating the engagement in these clinical roles by GPs during their early post-training period are lacking. What does this paper add? This paper is the first to document the prevalence of teaching and supervision undertaken by early career GPs as part of their regular clinical practice. We also demonstrate associations of practice rurality, country of medical graduation and undertaking non-practice-based clinical roles with GPs' engagement in teaching and supervisory roles. What are the implications for practitioners? Establishing current teaching patterns of GPs enables appropriate targeting of new strategies to sustain an effective teaching and supervisory capacity within general practice. The findings of the present study suggest that exploring focused strategies to facilitate and support international medical graduates to engage in teaching during their vocational training, aided by focused supervisor support, may be of particular value.

GP registrar consultations addressing menopause-related symptoms: a cross-sectional analysis.

OBJECTIVE: To investigate the prevalence and associations of general practitioner registrars' (trainees') management of women with menopause-related symptoms. METHODS: A cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. In ReCEnT registrars collected data of 60 consecutive consultations on three occasions during training. The outcome factor was menopause-related problems/diagnoses (compared with other problems/diagnoses). Associations of registrar, patient, practice, and consultation-independent variables were assessed by univariate and multivariable logistic regression. RESULTS: In all, 1,333 registrars conducted 189,774 consultations involving 295,017 problems/diagnoses. Of these, there were 1,291 problems/diagnoses (0.44% of all problems/diagnoses) relating to menopause. Significant multivariable independent associations of a problem being menopause-related were registrar female sex (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.30-3.26) and registrars working part-time (OR 0.84, 95% CI 0.72-0.98 for full-time work). Consultation-related associations included an increased number of problems addressed in the consultation (OR 1.29, 95% CI 1.21-1.37), and menopause-related problems/diagnoses not being new (OR 0.75, 95% CI 0.66-0.86). Significant educational associations were increased odds of recourse to in-consultation sources of information or assistance (OR 2.09, 95% CI 1.80-2.44) and of generating learning goals (OR 3.15, 95% CI 2.66-3.72). CONCLUSIONS: Registrars seek more assistance and further knowledge about menopause compared with other problems. Thus, they may find the area particularly challenging and could benefit from further education regarding managing menopause. Our findings may help inform the design of measures aimed at improving the delivery of menopause training for general practice registrars.

Gender differences in Australian general practice trainees performing procedures related to women's reproductive health: A cross-sectional analysis

BACKGROUND AND OBJECTIVES: Gender differences may exist in the performance of women's reproductive procedures. The aim of this study was to investigate the prevalence and association of general practice registrars' performance of women's procedures with trainees' gender, rurality of practice and in-consultation seeking of information or assistance. METHOD: This was a cross-sectional analysis of a cohort study of registrars' consultations in 2010­17. Registrars recorded 60 consecutive consultations during each six-month training term. The outcome was performance of a procedure related to women's reproductve health. RESULTS: Of 24,333 procedures performed in 332,700 encounters, 15,634 were on female patients and 6025 of those included procedures relating to women's reproductive health; 5002 were Pap smears (20.6%). Only 235 (4.7%) Pap smears were performed by male trainees. Performing women's procedures was significantly associated with trainees' gender, with an adjusted odds ratio of 4.80 (95% confidence interval: 4.10, 5.61). DISCUSSION: Our findings suggest that a gender difference exists in general practice trainees' frequency of performing women's procedures. Male trainees require more opportunities and support from their preceptors, clinical settings and training programs to perform these procedures.

Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis.

AIMS: Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars). METHODS: A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors. RESULTS: A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test). CONCLUSION: GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.

Changes in pathology test ordering by early career general practitioners: a longitudinal study.

OBJECTIVE: To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice. DESIGN: Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%. MAIN OUTCOME MEASURE: Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms. RESULTS: 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term. CONCLUSIONS: Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.

Procedural skills of Australian general practice registrars: A cross-sectional analysis.

BACKGROUND: Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training. METHODS: A cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed. RESULTS: In 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed. DISCUSSION: Registrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.

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.

Home visits and nursing home visits by early-career GPs: a cross-sectional study.

BACKGROUND: Home visits (HVs) and nursing home visits (NHVs) are accepted as core elements of general practice. There is concern regarding declining rates of HVs and an increasing demand for NHVs together with a perceived decreased willingness of younger GPs to provide these services. OBJECTIVES: To establish the prevalence and associations of recently vocationally qualified GPs ('graduates') performing HVs and NHVs. METHODS: A cross-sectional questionnaire-based study of recent (within 5 years) graduates of 3 of Australia's 17 regional general practice training programs. Outcome factors were performing, as part of current practice, HVs and NHVs. Factors associated with each outcome were assessed by logistic regression with graduate and current practice characteristics and vocational training experiences as independent variables. RESULTS: Of 230 responding graduates, 48.1% performed HVs and 40.6% performed NHVs in their current clinical GP role. Factors associated with both HVs and NHVs were participating in in-practice clinical teaching/supervision [odds ratios (ORs) 2.65 and 2.66], conducting HVs/NHVs during training (ORs 5.05 and 10.8) and working full-time (ORs for part-time work 0.20 and 0.29). Further associations with performing HVs were older GP age (compared to <36 years: ORs 3.65 for 36-40 and 2.53 for 41+), smaller practice size (OR 0.53 for larger practices), Australian undergraduate education (OR 0.31 for non-Australian) and greater number of years in their current practice as a qualified GP (OR 1.25 per year). CONCLUSIONS: Our findings of graduates' modest engagement with HVs and NHVs reinforce concerns regarding Australian general practice's capacity to accommodate the needs of an aging population.

Travel Medicine Encounters of Australian General Practice Trainees-A Cross-Sectional Study.

BACKGROUND: Travel medicine is a common and challenging area of clinical practice and practitioners need up-to-date knowledge and experience in a range of areas. Australian general practitioners (GPs) play a significant role in the delivery of travel medicine advice. We aimed to describe the rate and nature of travel medicine consultations, including both the clinical and educational aspects of the consultations. METHODS: A cross-sectional analysis from an ongoing cohort study of GP trainees' clinical consultations was performed. Trainees contemporaneously recorded demographic, clinical, and educational details of consecutive patient consultations. Proportions of all problems/diagnoses managed in these consultations that were coded "travel-related" and "travel advice" were both calculated with 95% confidence intervals (CIs). Associations of a problem/diagnosis being "travel-related" or "travel advice" were tested using simple logistic regression within the generalized estimating equations (GEE) framework. RESULTS: A total of 856 trainees contributed data on 169,307 problems from 108,759 consultations (2010-2014). Travel-related and travel advice problems were managed at a rate of 1.1 and 0.5 problems per 100 encounters, respectively. Significant positive associations of travel-related problems were younger trainee and patient age; new patient to the trainee and practice; privately billing, larger, urban, and higher socioeconomic status practices; and involvement of the practice nurse. Trainees sought in-consultation information and generated learning goals in 34.7 and 20.8% of travel advice problems, respectively, significantly more than in non-travel advice problems. Significant positive associations of travel advice problems were seeking in-consultation information, generation of learning goals, longer consultation duration, and more problems managed. CONCLUSIONS: Our findings reinforce the importance of focused training in travel medicine for GP trainees and adequate exposure to patients in the practice setting. In addition, our findings have implications more broadly for the delivery of travel medicine in general practice.