Prevalence and associations of provision of nursing home visits and home visits by early-career specialist general practitioners.

OBJECTIVE: To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early-career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs. METHODS: A cross-sectional study. DESIGN: A questionnaire-based study. SETTING: Australian general practice. PARTICIPANTS: Early-career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania. MAIN OUTCOME MEASURES: Current provision of NHV and HV. RESULTS: NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major-city practice, was strongly associated with performing NHV as an early-career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early-career specialist GP. On multivariable analyses, these were no longer statistically significant. CONCLUSION: Early-career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV.

Perceptions of the effectiveness of using patient encounter data as an education and reflection tool in general practice training.

Introduction Patient encounter tools provide feedback and potentially reflection on general practitioner (GP) registrars' in-practice learning and may contribute to the formative assessment of clinical competencies. However, little is known about the perceived utility of such tools. Aim To investigate the perceived utility of a patient encounter tool by GP registrars, their supervisors, and medical educators (MEs). Methods General practice registrars, supervisors and MEs from two Australian regional training organisations completed a cross-sectional questionnaire. Registrars rated how Registrar Clinical Encounters in Training (ReCEnT), a patient encounter tool, influenced their reflection on, and change in, clinical practice, learning and training. Supervisors' and MEs' perceptions provided contextual information about understanding their registrars' clinical practice, learning and training needs. Results Questionnaires were completed by 48% of registrars (n = 90), 22% of supervisors (n = 182), and 61% of MEs (n = 62). Most registrars agreed that ReCEnT helped them reflect on their clinical practice (79%), learning needs (69%) and training needs (72%). Many registrars reported changing their clinical practice (54%) and learning approaches (51%). Fewer (37%) agreed that ReCEnT influenced them to change their training plans. Most supervisors (68%) and MEs (82%) agreed ReCEnT reports helped them better understand their registrars' clinical practice. Similarly, most supervisors (63%) and MEs (68%) agreed ReCEnT reports helped them better understand their registrars' learning and training needs. Discussion ReCEnT can prompt self-reflection among registrars, leading to changes in clinical practice, learning approaches and training plans. Reaching its potential as an assessment for learning (as opposed to an assessment of learning) requires effective engagement between registrars, their supervisors and MEs.

Utilisation of in-consultation supervisor assistance in general practice training and personal cost to trainees: a cross-sectional study.

Aim The aim of the study was to establish whether two previously described barriers to effective in-consultation assistance-seeking by general practice (GP) vocational specialist trainees (ie concern about patient impressions of their competence, and discomfort presenting to supervisors in front of patients) influenced the frequency of trainee in-consultation assistance-seeking from their supervisor. Methods This was a cross-sectional study nested in the Registrar Clinical Encounters in Clinical Training ongoing cohort study of Australian GP trainees. Trainee participants completed contemporaneous records of 60 consecutive patient consultations, including whether supervisory assistance was sought. Trainees also completed a cross-sectional survey including items eliciting their beliefs about patient impressions and their own discomfort in seeking in-consultation supervisory assistance. These were factors of interest in multivariable logistic regression analyses; the outcome factor in both regression models was the seeking of in-consultation supervisory assistance. Results In 2018, 778 trainees (778/876, response rate 89%) completed the cross-sectional survey. No association was found between the odds of in-consultation help-seeking and perceived decrease in patient impressions of trainee competence (OR = 1.09; 95% CI: 0.91, 1.31; P = 0.36) or higher comfort presenting outside patients' hearing (OR = 0.9; 95% CI: 0.77, 1.05; P = 0.19). Discussion Contrary to expected utility models of help-seeking, trainees may not consider personal discomfort or impression management to be important enough, compared to patient safety and other considerations, to influence decisions regarding in-consultation help-seeking. Clinical supervisors should, nevertheless, consider the potential personal costs to trainees and maintain trainee self-esteem and confidence by providing in-consultation assistance in front of patients as comfortably and effectively as possible.

Prediction of general practice licensure/certification examination performance by a measure of 'questionable' activities in clinical practice: a retrospective cohort study.

PURPOSE: 'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP). METHODS: The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012-21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'-the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option). RESULTS: A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043]. CONCLUSION: Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination).

'Low-value' clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs' practice.

Nonevidence-based and 'low-value' clinical care and medical services are 'questionable' clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with their cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key nonevidence-based or low-value 'questionable' clinical practices. The study was nested in the Registrar Clinical Encounters in Training study-an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on Registrar Clinical Encounters in Training data from 2010 to 2020, was the score on the QUestionable In-Training Clinical Activities Index (QUIT-CAI), which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. A total of 3206 individual registrars (response rate 89.9%) recorded 406 812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15 560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training terms: incidence rate ratios (IRRs) of 0.91 [95% confidence interval (CI) 0.87, 0.95] and 0.85 (95% CI 0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12, 1.45), the patient being of non-English-speaking background (IRR 1.24; 95% CI 1.04, 1.47), the practice being in a higher socioeconomic area decile (IRR 1.01; 95% CI 1.00, 1.02), small practice size (IRR 1.05; 95% CI 1.00, 1.10), shorter consultation duration (IRR 0.99 per minute; 95% CI 0.99, 1.00), and fewer problems addressed in the consultation (IRR 0.84; 95% CI 0.79, 0.89) for each additional problem]. Senior registrars' clinical practice entailed less 'questionable' clinical actions than junior registrars' practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests that continuity should be supported and facilitated during GP training (and in established GPs' practice).

The prevalence and associations of Australian early-career general practitioners' provision of after-hours care.

INTRODUCTION: Access to after-hours care (AHC) is an important aspect of general practice service provision. OBJECTIVE: To establish the prevalence and associations of early-career GPs' provision of AHC. DESIGN: An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT-UP) cross-sectional questionnaire-based study. Participants were early-career GPs (6-month to 2-year post-Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after-hours care'. Associations of the outcome were established using multivariable logistic regression. FINDINGS: Three hundred and fifty-four early-career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80-10.80], p < 0.001). Current rural location and in-training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis. DISCUSSION: Early-career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after-hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners. CONCLUSION: These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training.

Influenza presentations and use of neuraminidase inhibitors by Australian general practice registrars: a cross-sectional analysis from the ReCEnT study.

OBJECTIVE: This study aims to establish prevalence and associations of (1) influenza and influenza-like illness (IILI) presentations to Australian general practice (GP) registrars (trainees) and (2) the use of neuraminidase inhibitors (NAIs) by GP registrars for new presentations of IILI, for the 10 years leading up to the COVID-19 pandemic in Australia (2010-2019). DESIGN: This was a cross-sectional analysis of the Registrar Clinical Encounters in Training ongoing inception cohort study of the in-consultation experience and clinical behaviours of GP registrars. Data are collected by individual registrars three times (from 60 consecutive consultations each time) at 6 monthly intervals. Data include diagnoses/problems managed and medicines prescribed, along with multiple other variables. Univariate and multivariable logistic regression was used to establish associations of registrars seeing patients with IILI and of prescribing NAIs for IILI. SETTING: Teaching practices within the Australian general practitioner specialist vocational training programme. Practices were located in five of the six Australian states (plus one territory). PARTICIPANTS: GP registrars in each of their three compulsory 6-month GP training terms. RESULTS: From 2010 to 2019, 0.2% of diagnoses/problems seen by registrars were IILI. 15.4% of new IILI presentations were prescribed an NAI. IILI diagnoses were less likely in younger (0-14) and older (65+) age groups, and more likely in an area of higher socioeconomic advantage. There was considerable variation in NAI prescribing between regions. There was no significant association of prescribing NAIs with age or Aboriginal and/or Torres Strait Islander patients. CONCLUSIONS: IILI presentations were more likely among working-age adults and not among those groups at higher risk. Similarly, high-risk patient groups who would benefit most were not more likely to receive NAIs. The epidemiology and management of IILI has been distorted by the COVID-19 pandemic, but the burden of influenza in vulnerable populations must not be overlooked. Appropriately targeted antiviral therapy with NAIs influences outcomes for vulnerable patients. General practitioners manage the majority of IILI in Australia, and understanding GP IILI presentation and NAI prescribing patterns is a key first step to enabling sound and rational prescribing decisions for better patient outcomes.

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.

Temporal trends in, and associations of, early-career general practitioner prescriptions of second-line Type 2 Diabetes medications, 2010-2018.

INTRODUCTION: Second-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas. MATERIALS AND METHODS: A longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework. RESULTS: 2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],p<0.001), and a 77% per (two-to-three-year) time-interval increase in initiation (OR = 1.77,[95% CI:1.30-2.43],p = <0.001) of 'new' medications compared to sulphonylureas. 'New' medications were prescribed less for non-English-speaking patients. There was some regional variation in prescribing. CONCLUSION: Registrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly.

Climate change and Australian general practice vocational education: a cross-sectional study.

BACKGROUND: Climate change is a rapidly progressing threat to global health and well-being. For general practitioners (GPs) currently in training, the effects of climate change on public health will shape their future professional practice We aimed to establish the prevalence and associations of Australian GP registrars' (trainees') perceptions of climate change as it relates to public health, education, and workplaces. METHODS: A cross-sectional questionnaire-based study of GP registrars of three Australian training organizations. The questionnaire assessed attitudes regarding adverse health effects of climate change (over the next 10-20 years), and agreement with statements on (i) integrating health impacts of climate change into GP vocational training, and (ii) GPs' role in making general practices environmentally sustainable. RESULTS: Of 879 registrars who participated (response rate 91%), 50.4% (95% CI 46.8%, 54.0%) perceived a large or very large future health effect of climate change on their patients, and 61.8% (95% CI 58.6%, 65.0%) agreed that climate health impacts should be integrated within their education programme. 77.8% (95% CI 74.9%, 80.4%) agreed that GPs should have a leadership role in their practices' environmental sustainability. Multivariable associations of these attitudes included female gender, training region, and (for the latter two outcomes) perceptions of future impact of climate change on patient health. CONCLUSIONS: GP registrars are motivated to receive climate health education and engage in environmentally sustainable practice. This may primarily reflect concern for future practice and patient care.

Cross-sectional analysis of the clinical work hours of early-career general practitioners.

BACKGROUND AND OBJECTIVES: The clinical working hours of early-career general practitioners (GPs) are an important factor in Australian GP workforce planning. This study aimed to establish the prevalence and associations of early-career GPs working full time (nine or more sessions per week) in clinical practice. METHOD: This was a cross-sectional questionnaire-based study of alumni (from six months to two years post-Fellowship) from three regional training organisations. Multivariable logistic regression was used to establish factors associated with alumni working full time. RESULTS: Of 356 currently practising early-career alumni participants, 30% worked full time. Factors associated with working full time included spouse/partner employment and family structure and any examination failure. Factors associated with working less than full time included female gender, being an Australian medical graduate, provision of other medical work and having taken additional leave during training. DISCUSSION: A high proportion of early-career GPs working part time in clinical general practice has implications for workplace planning, as GPs seek workload diversity and flexibility across their career stages.

Immunising older Australians: Pre-COVID-19 associations of opportunistic immunisation in general practice registrar consultations.

BACKGROUND AND OBJECTIVES: Vaccine uptake in older Australians is suboptimal. This exploratory study aims to establish the associations of opportunistic older person immunisation in general practice registrars' practice. METHOD: This study was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. Univariate and multivariable regressions explored associations between vaccine recommendations and patient, registrar, practice and consultation factors. RESULTS: A total of 2839 registrars provided data on 74,436 consultations. Associations of lower odds of immunisation included Aboriginal and Torres Strait Islander peoples (odds ratio [OR] 0.69; 95% confidence interval [CI]: 0.50, 0.96), rural/remote practice location (OR 0.75; 95% CI: 0.58, 0.98, compared with major cities) and in areas of greater relative socioeconomic disadvantage (OR per decile 1.03; 95% CI: 1.01, 1.05). Patients new to the practice (OR 2.46; 95% CI: 2.06, 2.94), or to the registrar (2.02; 95% CI: 1.87, 2.18) had higher odds of receiving an immunisation. DISCUSSION: Our findings suggest that general practice registrars may be proactively facilitating immunisation in new patients, but that inequities in vaccination persist.

'Low-value' clinical care in general practice: associations of low value care in GP trainees' practice, including formative and summative examination performance - protocol for cross-sectional and retrospective cohort study analyses using the QUestionable In Training Clinical Activities (QUIT-CA) index.

INTRODUCTION: 'Low value' clinical care and overuse of medical services are 'questionable' clinical activities that entail provision of medical services that are more likely to cause harm than good or whose benefit is disproportionately low compared with its cost. This study will seek to establish clinical practice associations of a non-observed work-based assessment of general practitioner (GP) trainees' (registrars') questionable practice (the QUestionable In Training Clinical Activities (QUIT-CA) index). We will also explore association of the QUIT-CA index with a formative observed work-based assessment, and will establish if registrars' QUIT-CA indexes are associated with summative examination performance. METHODS AND ANALYSIS: We will conduct three analyses, all using data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing (from 2010) cohort study in which Australian GP registrars record details of their in-consultation clinical and educational practice. The QUIT-CA index is compiled from ReCEnT consultation data. A cross-sectional analysis, using negative binomial regression, will establish clinical practice associations of the QUIT-CA index. A cross-sectional analysis using linear regression will be used to establish associations of QUIT-CA index with formative observed in-practice assessment (the General Practice Registrar-Competency Assessment Grid). A retrospective cohort study analysis using linear regression will be used to establish associations of the QUIT-CA index with summative examination performance (Royal Australian College of General Practice fellowship examinations results). ETHICS AND DISSEMINATION: The study has ethical approval from the University of Newcastle HREC(H-2009-0323). Findings will be disseminated in peer-reviewed journal articles and conference presentations.

Antibiotic prescribing for upper respiratory tract infections and acute bronchitis: a longitudinal analysis of general practitioner trainees.

BACKGROUND: Most antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis is inappropriate. Substantive and sustained reductions in prescribing are needed to reduce antibiotic resistance. Prescribing habits develop early in clinicians' careers. Hence, general practice (GP) trainees are an important group to target. OBJECTIVES: We aimed to establish temporal trends in antibiotic prescribing for URTIs and acute bronchitis/bronchiolitis by Australian GP trainees (registrars). METHODS: A longitudinal analysis, 2010-2019, of the Registrars Clinical Encounters in Training (ReCEnT) dataset. In ReCEnT, registrars record clinical and educational content of 60 consecutive consultations, on 3 occasions, 6 monthly. Analyses were of new diagnoses of URTI and acute bronchitis/bronchiolitis, with the outcome variable a systemic antibiotic being prescribed. The independent variable of interest was year of prescribing (modelled as a continuous variable). RESULTS: 28,372 diagnoses of URTI and 5,289 diagnoses of acute bronchitis/bronchiolitis were recorded by 2,839 registrars. Antibiotic prescribing for URTI decreased from 24% in 2010 to 12% in 2019. Prescribing for acute bronchitis/bronchiolitis decreased from 84% to 72%. "Year" was significantly, negatively associated with antibiotic prescribing for both URTI (odds ratio [OR] 0.90; 95% confidence interval [CI]: 0.88-0.93) and acute bronchitis/bronchiolitis (OR 0.92; 95% CI: 0.88-0.96) on multivariable analysis, with estimates representing the mean annual change. CONCLUSIONS: GP registrars' prescribing for URTI and acute bronchitis/bronchiolitis declined over the 10-year period. Prescribing for acute bronchitis/bronchiolitis, however, remains higher than recommended benchmarks. Continued education and programme-level antibiotic stewardship interventions are required to further reduce registrars' antibiotic prescribing for acute bronchitis/bronchiolitis to appropriate levels.

It is well known that antibiotic consumption can cause antibiotic resistance. Most antibiotic prescribing happens in general practice. The common cold (upper respiratory tract infections) and cough (acute bronchitis) are 2 conditions that antibiotics are often prescribed for, but are not needed. There is considerable evidence that antibiotics do not help these conditions improve, and guidelines in Australia state that they are not a treatment option. General practitioners at the beginning of their career form prescribing habits early on. In light of the problem of antibiotic resistance, it is important to know how new doctors prescribe antibiotics, as they may do this for the rest of their career. We investigated their prescribing for the common cold and cough, from 2010 to 2019. We found that overall their prescribing has been declining over the last 10 years, but prescribing for cough is still too high. There needs to be more interventions in this group of doctors to reduce prescribing for this condition.

Socioeconomic status of practice location and Australian GP registrars' training: a cross-sectional analysis.

BACKGROUND: Socioeconomic status (SES) is a major determinant of health. In Australia, areas of socioeconomic disadvantage are characterised by complex health needs and inequity in primary health care provision. General Practice (GP) registrars play an important role in addressing workforce needs, including equitable health care provision in areas of greater socioeconomic disadvantage. We aimed to characterize GP registrars' practice location by level of socioeconomic disadvantage, and establish associations (of registrar, practice, patient characteristics, and registrars' clinical behaviours) with GP registrars training being undertaken in areas of greater socioeconomic disadvantage. METHODS: A cross-sectional analysis from the Registrars' Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multi-centre, cohort study that documents 60 consecutive consultations by each GP registrar once in each of their three six-monthly training terms. The outcome factor was the practice location's level of socioeconomic disadvantage, defined using the Index of Relative Socio-economic Disadvantage (SEIFA-IRSD). The odds of being in the lowest quintile was compared to the other four quintiles. Independent variables related to the registrar, patient, practice, and consultation. RESULTS: A total of 1,736 registrars contributed 241,945 consultations. Significant associations of training being in areas of most disadvantage included: the registrar being full-time, being in training term 1, being in the rural training pathway; patients being Aboriginal or Torres Strait Islander, or from a non-English-speaking background; and measures of continuity of care. CONCLUSIONS: Training in areas of greater social disadvantage, as well as addressing community need, may provide GP registrars with richer learning opportunities.

Prevalence and associations of rural practice location in early-career general practitioners in Australia: a cross-sectional analysis.

OBJECTIVES: To: (1) establish the prevalence of urban, regional, rural and remote practice location of early-career general practitioners (GPs); and (2) examine demographic and training-related characteristics associated with working in regional, rural or remote areas post attainment of vocational general practice qualifications. DESIGN: Cross-sectional, questionnaire-based study, combined with contemporaneously collected data from participants' prior vocational training. SETTING: Australian general practice. PARTICIPANTS: Newly vocationally qualified GPs (ie, within 6 months-2 years post fellowship) who had completed vocational training with regional training organisations in New South Wales, Australian Capital Territory, eastern Victoria, and Tasmania between January 2016 and July 2018. PRIMARY OUTCOME MEASURE: Rurality of post-fellowship practice location, as defined by Modified Monash Model (MMM) geographical classifications, based on current practice postcode. Prevalence of regional/rural/remote ('rural') practice was described using frequencies, and associations of rural practice were established using multivariable logistic regression, considering a range of demographic factors and training characteristics as independent variables. RESULTS: A total of 354 participants completed the questionnaire (response rate 28%) with 319 providing information for their current practice location. Of these, 100 (31.4%) reported currently practising in a rural area (MMM2-7). Factors most strongly associated with practising in a rural area included having undertaken vocational GP training in a rural location OR 16.0 (95% CI 6.79 to 37.9); p<0.001; and undertaking schooling in rural area prior to university OR 4.21 (1.98, 8.94); p<0.001. CONCLUSIONS: The findings suggest that vocational training experience may have a role in rural general practice location post fellowship, attenuating the previously demonstrated 'leakage' from the rural practice pipeline.

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.

Socioeconomic disadvantage and the practice location of recently Fellowed Australian GPs: a cross-sectional analysis.

BACKGROUND: Socioeconomic disadvantage and the 'inverse care law' have significant effects on the health and well-being of Australians. Early career GPs can help address the needs of socioeconomically disadvantaged communities by choosing to practice in these locations. This study addressed an evidence gap around GPs post-Fellowship (within 2 years) practice location, and whether practice location is related to postgraduate vocational training. METHODS: This was a cross-sectional questionnaire-based study of recently Fellowed GPs from New South Wales, the Australian Capital Territory, Victoria and Tasmania. Questionnaire items elicited information about participants' current practice, including location. Where consent was provided, participants' questionnaire responses were linked to previously collected vocational GP training data. The outcome factor in analyses was practice location socioeconomic status (SES): the four deciles of greater socioeconomic disadvantage versus locations with a higher SES. SES was classified according to the Socio-Economic Indexes for Areas - Index of Relative Socioeconomic Disadvantage. Multivariable logistic regression was undertaken. RESULTS: Of participants currently working in clinical general practice, 26% were practicing in the four deciles of greater socioeconomic disadvantage. Significant multivariable associations of working in these locations included having trained in a practice located in an area of greater socioeconomic disadvantage (odds ratio (OR) 3.14), and having worked at their current practice during vocational training (OR 2.99). CONCLUSION: Given the association of training and practice location for recently Fellowed GPs, policies focused on training location may help in addressing ongoing workforce issues faced by areas of higher socioeconomic disadvantage.

Influence of rurality on general practitioner registrars' participation in their practice's after-hours roster: A cross-sectional study.

OBJECTIVE: To investigate whether practice rurality and rural training pathway are associated with general practitioner registrars' participation in their practice's after-hours care roster. DESIGN: A cross-sectional analysis of data (2017-2019) from the Registrar Clinical Encounters in Training study, an ongoing inception cohort study of Australian general practitioner registrars. The principal analyses used logistic regression. SETTING: Three national general practitioner regional training organisations across 3 Australian states. PARTICIPANTS: General practitioner registrars in training within regional training organisations. MAIN OUTCOME MEASURE: Involvement in practice after-hours care was indicated by a dichotomous response on a 6-monthly Registrar Clinical Encounters in Training study questionnaire item. RESULTS: 1576 registrars provided 3158 observations (response rate 90.3%). Of these, 1574 (48.6% [95% confidence interval: 46.8-50.3]) involved registrars contributing to their practice's after-hours roster. In major cities, 40% of registrar terms involved contribution to their practice's after-hours roster; in regional and remote practices, 62% contributed to the after-hours roster. On multivariable analysis, both level of rurality of practice (odds ratio(OR) 1.75, P = .007; and OR 1.74, P = .026 for inner regional and outer regional/remote locations, respectively, versus major city) and rural training pathway of registrar (OR 1.65, P = .008) were significantly associated with more after-hours roster contribution. Other associations were registrars' later training stage, larger practices and practices not routinely bulk billing. Significant regional variability in after-hours care was identified (after adjusting for rurality). CONCLUSION: These findings suggest that registrars working rurally and those training on the rural pathway are more often participating in practice after-hours rosters. This has workforce implications, and implications for the educational richness of registrars' training environment.

Provision of other medical work by Australian early-career general practitioners: a cross-sectional study.

Introduction There is a trend towards GPs diversifying their role by working in health areas beyond general practice. However, little is known about whether this trend is apparent among early-career GPs once they make the transition from training to independent practice. Aim To describe the prevalence of and characteristics associated with early-career GPs providing other medical work. Methods A cross-sectional questionnaire-based study of GPs ('alumni') who had fellowed within the past 2 years from three of Australia's nine regional training programs. The outcome factor was provision of medical work in addition to clinical general practice. Associations of independent variables (encompassing alumni demographics, current practice characteristics and vocational training experience) with the outcome were estimated using univariate and multivariable logistic regression. Results Of 339 responding alumni, 111 (33%) undertook other regular medical work. Sixty-five (59%) of these were in medical education. In multivariable analysis, factors associated with providing other medical work were having a spouse/partner not in the workforce (odds ratio (OR) 5.13), having done any training part-time (OR 2.67), providing two or more of home visits, nursing home visits and after-hours care (OR 2.20), working fewer sessions per week (OR 0.74), and currently working in an area of lower socio-economic status (OR 0.84). Having dependent children (OR 0.27), and being female (OR 0.43) were associated with not providing other medical work. Discussion In this study, many early-career GPs are providing other medical work, particularly medical education. Acknowledging this is important to general practice workforce planning and education policy.