Neil Spike

Identification of Aboriginal and Torres Strait Islander status in healthcare settings is essential for the delivery of culturally appropriate care. Under-identification is common and practitioner confidence is a known barrier. The objective of this research was to document the self-reported confidence of general practice registrars in identifying the Aboriginal and Torres Strait Islander status of their patients, and associations of this confidence. This research used cross-sectional analysis of survey and patient encounter data of general practice registrars training across five Australian states. Of the 698 registrars (97.5% response rate) who participated in the study, 74.5% had a high level of confidence in identifying a patient's Aboriginal and Torres Strait Islander status. Older and more senior registrars had significantly greater confidence. There was also a significant association with the registrars' training provider. More than a quarter of registrars reported low confidence for this basic consultation skill. Our findings will inform general prac-tice vocational training and continuing professional development, and reinforce the importance of a comprehensive, system-wide approach to the identification of patients' Aboriginal or Torres Strait Islander status.

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. This article discusses the implications of this information for Australian general practice training. 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.

There is concern about whether general practice registrars gain sufficient exposure to, and confidence in caring for, many pae-diatric conditions during their apprenticeship training. General practice registrars' referral patterns for paediatric conditions over-all or for specific conditions, including behavioural or mental health diagnoses, are unknown. The aim of this study was to assess the relative rates of referral by general practice registrars for children, compared with adults, specifically for those with behavioural or mental health diagnoses. A secondary analysis of 83,445 encounters from the Registrar Clinical Encounters in Training (ReCEnT) dataset was undertaken. More than half of children (52%) with a behavioural or mental health problem were referred to specialty care, compared with only 23% of adults. For all other conditions, only 9% of children received specialty referral, compared with 12% of adults. Although a certain proportion of behavioural or mental health issues in children may require either diagnostic assistance or aid in management, it is unclear whether more than half are unable to be cared for by a general practice registrar without referral.

A broad case-mix in family physicians’ (general practitioners’, GPs’) vocational trainee experience is deemed essential in producing competent independent practitioners. It is suggested that the patient-mix should include common and significant conditions and be similar to that of established GPs. But the content of contemporary GP trainees’ clinical experience in training is not well-documented. In particular, how well trainees’ experience reflects changing general practice demographics (with an increasing prevalence of chronic disease) is unknown. We aimed to establish levels of trainees’ clinical exposure to chronic disease in training (and associations of this exposure) and to establish content differences in chronic disease consultations (compared to other consultations), and differences in trainees’ actions arising from these consultations. A cross-sectional analysis from the Registrars’ Clinical Encounters in Training (ReCEnT) study, a cohort study of GP registrars’ (trainees’) consultations in four Australian GP training organisations. Trainees record detailed data from 60 consecutive consultations per six-month training term. Diagnoses/problems encountered are coded using the International Classification of Primary Care-2 PLUS (ICPC-2 PLUS). A classification system derived from ICPC-2 PLUS was used to define diagnoses/problems as chronic/non-chronic disease. The outcome factor for analyses was trainees’ consultations in which chronic disease was encountered. Independent variables were a range of patient, trainee, practice, consultation and educational factors. Of 48,112 consultations (of 400 individual trainees), 29.5% included chronic disease problems/diagnoses. Associations of a consultation including chronic disease were the patient being older, male, and having consulted the trainee previously, and the practice routinely bulk-billing (not personally charging) patients. Consultations involving a chronic disease lasted longer, dealt with more problems/diagnoses, and were more likely to result in specialist referrals and trainees generating a personal learning goal. They were associated with less pathology tests being ordered. Trainees saw chronic disease less frequently than have established GPs in comparable studies. The longer duration and more frequent generation of learning goals in chronic disease-containing consultations suggest trainees may find these consultations particularly challenging. Our findings may inform the design of measures aimed at increasing the chronic disease component of trainees’ patient-mix.

The impact of the ageing population on the paediatric clinical experiences of general practice registrars is unknown. A secondary analysis of the Registrar Clinical Encounters in Training dataset to examine the distribution of visit proportions and length, and the most common diagnoses seen (by patient age) by registrars in the general practice setting. Children aged less than 4 years comprised 9% of patients seen, 5-14 years, 8%, and 15-19 years comprised 6%. Registrars spent the most time in consultations with patients aged 65+ years and the least time with children aged 5-14 years. Registrars reported significantly more extended consultations of more than 40 minutes with seniors than with children aged less than 4 years. Of all consultations for children aged less than 4 years, only one was for more than 40 minutes. Exposure of general practice registrars to chronic illness in children, and to a range of diagnostic conditions, may be quite limited. Specific efforts and interventions may be required to ensure that registrars gain adequate experience to provide competent primary care to all age groups.

There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research.