Rescuing the profession we love: general practice training sector recommendations for improving the attractiveness of general practice training. A qualitative analysis.

OBJECTIVES: To investigate the views of the general practice training sector about responding to recruitment challenges, with the aim of identifying effective initiatives and other solutions. STUDY DESIGN: Qualitative study; focus group discussion of recommendations from a medical educator workshop. SETTING, PARTICIPANTS: An initial online appreciative enquiry workshop for medical educators followed by focus group discussions by a broader selection of people involved in general practitioner training (Royal Australian College of General Practitioners fellows, supervisors, practice managers, medical educators, registrars). MAIN OUTCOME MEASURES: Key overarching themes and major recommendations for increasing recruitment derived from focus group responses to workshop recommendations, based on qualitative descriptive analysis. RESULTS: The 26 medical educators at the workshop made four major recommendations: increase the number of student and junior doctor clinical placements in general practice; increase exposure of students and junior doctors to general practitioner teachers and educators; improve general practitioner trainee pay and entitlements; and improve the integration of general practice and hospital patient care and professional relationships. Thirty-four semi-structured focus group participants broadly supported the recommendations, provided that supervisors and training practices were adequately compensated for the effects on workloads, income, and patient care. Two overarching themes infused participant responses: "rescuing the profession we love" (reflecting participants' passion for general practice and their sense of threat), and "no idea what general practitioners do" (perceptions of being misunderstood and misrepresented by hospital-based practitioners). CONCLUSIONS: Clinicians, educators, and policy makers should work together to increase the number of high quality, adequately supported student and junior doctor placements in general practice, improve intra-professional relationships, and trial new models of general practitioner trainee payment and conditions.

Digital health access, uptake, literacy and trust in people with experience of homelessness.

BACKGROUND AND OBJECTIVES: Although digital health promises improved healthcare efficiency and equity, access and uptake might be low in disadvantaged populations. We measured access to digital health technology, the uptake of digital health, digital health literacy and COVID-19 vaccination intentions in an inner-city Australian population experiencing homelessness. METHOD: An existing Australian survey, including a validated digital health literacy measure (eHealth Literacy Scale [eHEALS]), was modified and distributed in three general practices specifically targeting the homeless population. Data analysis used appropriate descriptive statistics and correlation coefficients. RESULTS: Eighty-three respondents completed the survey in 2021. Digital health uptake was much lower than in the general Australian population in 2019-20, despite good access to working smart phones and connectivity. Digital health literacy was positively associated with uptake. Internet-sourced information was trusted less than information from a general practitioner. DISCUSSION: Further work is needed to understand the perceived usefulness and sociocultural compatibility of digital health in different subpopulations experiencing homelessness, including susceptibility to misinformation.

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.

Reimagining rural clinical education from lessons learnt during COVID.

BACKGROUND: Securing access to sufficient and focussed learning experiences is a perennial challenge for medical trainees. This challenge was accentuated during the COVID-19 pandemic lockdowns and with physical isolation processes that decreased in-person patient presentations and a shift to telehealth consultations. This situation has prompted the need to optimise the available experiences and educational responses to overcome the limitations in the number, quantum and range of available clinical learning experiences. METHODS: Semi-structured interviews were conducted with medical practice teams in four rural general practices to understand how medical trainees' education in rural general practices can be sustained in such circumstances. FINDINGS: Key considerations included optimising the available experiences to assist medical trainees to generate the kinds of mental models needed by trainees to conduct medical work, and particularly, when it became even more restricted through remote or physically distanced consultations. It also identified lessons learnt during COVID-19 pandemic lockdowns to inform and improve the provision of trainees' experiences in such practices. DISCUSSION: Providing experiences for trainees to participate fully in clinical activities is imperative. A sequenced set of experiences was proposed to incrementally prepare trainees to engage in and conduct clinical consultations remotely using digital technologies. CONCLUSION: Such an approach may not always be easy or possible to enact but offers a pathway of experiences most likely to lead to positive outcomes for the trainees whilst maintaining patient care and safety considerations.

Where the joy comes from: a qualitative exploration of deep GP-patient relationships.

BACKGROUND: Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives. METHODS: Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis. RESULTS: Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation. CONCLUSIONS: We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates.

Holding the complex whole: Generalist philosophy, priorities and practice that facilitate whole-person care.

BACKGROUND: Generalist work is often complex, especially in the face of undifferentiated, uncertain, uncomfortable or unremitting presentations. This complexity can be exacerbated by difficult social circumstances and health system constraints, as well as by dissonance between patient and clinician conceptions of ideal care. OBJECTIVE: This article offers philosophical and practical encouragement to help general practitioners (GPs) 'be with' patients, care for their own needs and value their complex work. DISCUSSION: Caring for the whole person is challenging. When done well, this complex care may look simple. Alongside biomedical knowledge, generalists require sophisticated relational sensitivity and capacity to notice and attend to context, culture, meaning and subjective inner experience, including the person's strengths and deepest fears. Generalist philosophy, priorities and clinical skills are named in this paper as part of the ongoing effort to help GPs value, hone and protect the often-misunderstood complexity of their work.

Work-based feedback conversations with GP teachers.

INTRODUCTION: Feedback may play out in the general practice workplace less usefully than anticipated by educators. We investigated work-based feedback conversations about directly observed student tasks embedded in the supervisor's clinical consultations with patients. METHODS: Feedback conversations between GP teachers and medical students and subsequent student reflections were audio-recorded. Student and GP teacher focus groups were also conducted and transcribed professionally. An iterative, qualitative descriptive analysis integrating all transcripts was undertaken. Findings are discussed under the descriptive categories of feedback structure, content and perceived value. RESULTS: Twenty feedback conversations (total duration of 85 min) between five GP teachers, nine students and 20 student reflections (total duration of 58 min) were analysed. GP teachers actively engaged students in reflection and used balancing scripts and soft correction strategies. Students appeared to have some difficulty steering feedback conversations, which focused more on general skills than case-specific content knowledge. The recorded conversations were fragments of ongoing, in-practice teaching and learning, explicit and implicit. Student reflections suggested that they were able to grasp learning points effectively and identify room for growth. Praise and positive self-feedback appeared to reassure students, particularly when they were disappointed by their performances. DISCUSSION: Formal 'set-piece' feedback conversations may be a useful opportunity to explicitly surface and/or reinforce previous 'in-practice' reflection and feedback using a systematic structure. They may also reassure and encourage students and foster positive educational alliances. Students value in-practice and on-practice feedback but may prefer more control of the latter conversations.

Enhanced primary care after hospitalization: General practitioner, pharmacist and patient feedback from the REMAIN HOME trial.

BACKGROUND: Pharmacist and general practitioner (GP) collaborative models of care are continuing to evolve in the Australian primary care setting. The REMAIN HOME study investigated whether a pharmacist integrated into 14 different primary care teams in general practice (the "practice pharmacist model") reduces readmission to hospital for patients prescribed five or more long term medicines or high risk comorbidities. The aim of this paper is to describe the attitudes of GPs, patients, and practice pharmacists towards this model of pharmacist and GP collaboration. METHODS: To explore the views and opinions about the model of care (pharmacist integration into general practice), participating GPs were invited to complete a survey that included the 13-item validated Attitudes Toward Collaboration Instrument for GPs (ATCI-GP) one month after the pharmacist had been integrated into the practice. Survey instruments were also created for patients and pharmacist participating in the intervention. These were deployed after the initial consultation and at the end of the intervention period respectively, to elicit each stakeholders' views and experiences of the service. Data were analysed using descriptive statistics. RESULTS: In total, 48 GPs, 43/101 patients (43%) and 11/13 practice pharmacists (85%) completed the survey. The majority of GPs strongly agreed or agreed with all statements of the ATCI-GP, indicating support for the practice-integrated pharmacist model. Most patients agreed that there was a role for a pharmacist in their general practice (n = 28, 76%), and that they would like to see the pharmacist again (n = 34, 79%). Pharmacists indicated that they enjoyed the role (n = 11, 91%) and found the position professionally satisfying (n = 9, 82%). Most pharmacists agreed that co-location (inside the general practice itself, rather than in a co-located pharmacy) was beneficial (n = 8, 73%) and all pharmacists (100%) acknowledged the benefits of having access to patient medical records. Free text comments from GPs were enthusiastic overall, although some concerns about the financial viability of the model in the current setting were raised. The primary limitation of the study is the anonymous nature of the survey, meaning clustering of responses across the 14 sites could not be determined. CONCLUSIONS: A practice pharmacist model of care in the Australian primary care setting appears to be accepted by GPs, patients and practice pharmacists and provides promising evidence that this model of care is likely to be well accepted if implemented more broadly in the Australian healthcare setting, provided that it can be appropriately remunerated.

'Things we are expected to just do and deal with': Using the medical humanities to encourage reflection on vulnerability and nurture clinical skills, collegiality, compassion, and self-care.

The Vulnerability in Medicine (ViM) program was developed to provide protected time and psychologically safe spaces for third-year medical students to consider challenges in the doctor-patient relationship and the clinical workplace. A suite of discussion-prompts presented in a small-group learning environment provides a springboard for students to reflect on their development as clinicians, understand the personhood of their patients, explore the therapeutic relationship, and consider emotional responses and personal, cultural, and social assumptions that impact on care. The program supports students to recognise vulnerability in themselves, the patient, their tutors, and the wider clinical team, as they face the challenge of aligning the clinician they want to become with ideals of professionalism and the imperfect clinical workplace. This 6­week program focuses on the vulnerability of patients, students, and doctors in a weekly tutorial interposed with clinical placements primarily in geriatric, rehabilitation, or palliative medicine. The tutorials draw from the medical humanities and use experiential, reflective, and narrative learning techniques. They are facilitated by generalist clinicians who model their own vulnerability, humanity, and reflective practice by sharing tutorial tasks equally with students. Students report feeling supported, and appreciate the opportunity to discuss ethical, psychosocial, and emotional aspects of medicine whilst reflecting on what medical practice means to them. Tutors experience a deeper appreciation of student journeys and their own vocations as clinicians and teachers. The sharing of vulnerability exposes the humanity of patients, students, and clinicians, and sustains our whole-person approach to the care of patients, students, and ourselves.

The educational affordances of external clinician observation of GP trainee consultations.

AIM: There is widespread agreement about the importance of direct observation of trainee practice by clinical supervisors. Less is known about observation by observers external to the supervisory team. We explored the educational affordances of external observation of GP trainee consultations for educational and assessment purposes, from the perspectives of both observers and trainees. METHOD: GP medical educators, who were scheduled to observe sessions of GP trainee consultations, were recruited as participant observers. They completed field notes, reflective memos and a focus group discussion, and conducted post-observation interviews with trainees, focused on trainee experiences of accessing educational input from supervisors and observers during the sessions. Thematic analysis was guided by constructivist realism and socio-cultural theory. RESULTS: A total of 23 observation sessions (131 observed patient consultations), 33 trainee interviews and 23 observer reflections were completed. External observers embraced teaching, coaching and pastoral opportunities, rather than being 'flies on the wall', despite also having research and assessment roles. They gained useful insights into the challenges of obtaining and providing in-consultation supervisory assistance and provided some in-consultation guidance themselves. Both trainees and observers experienced the sessions as valuable and collegial. Trainees appreciated post-consultation feedback conversations: topics included consultation challenges, managing uncertainty and variation in clinical practice. Patient expectations and pre-existing relationships influenced the distinctive interpersonal dynamic of the externally observed consultation. CONCLUSIONS: The educational affordances and interpersonal dynamics of external observation differ from supervisor observation. We recommend wider use in clinical training of observers who cross between educator and clinician communities.

A crisis is also an opportunity: GP teachers' views on continuing clinical placements in general practice during the evolving COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Early in the COVID-19 pandemic, some universities suspended student placements in general practice. The aim of this study was to explore the views of general practitioners (GPs) teaching in clinical practice ('GP teachers'). METHOD: Semi-structured interviews were held with 15 GP teachers in southeast Queensland from June to August 2020. RESULTS: Challenges included lack of masks and space, and concerns about infection control, medico-legal liability and student learning. Telehealth created more time for reflection and accessing information, increased student access to sensitive consultations, and provided opportunities to think-through rather than rote-do physical examinations. Students could be an extra pair of hands, also accessing and implementing the latest public health advice. GP teachers wanted clear communication and guidance from universities and for students to be trained in infection control and telehealth skills. DISCUSSION: Findings suggest that many GP teachers can be supported to continue clinical placements during an evolving crisis. The pandemic presented many challenges for general practice but also new opportunities for students to learn and contribute in practice.

Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis.

BACKGROUND: Readmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community. OBJECTIVE: To assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions. METHODS: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect. RESULTS: In total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR = 0.87, CI:0.79-0.97, p = 0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR = 0.78, CI:0.67-0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR = 0.92, CI:0.80-1.06; low certainty of evidence). CONCLUSIONS: The totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.

Heard, known, and safe in general practice? An interview study with patients with severe and persistent mental illness.

BACKGROUND: Although GPs provide care to many patients with severe and persistent mental illness, the role and skillset of the GP in this space are contested. Patients are less satisfied with GP care of mental health than physical health issues. AIM: To explore patient expectations and experiences of GP roles in their mental health, and identify opportunities for improving mental health care in general practice. DESIGN & SETTING: Patient participants were recruited from community mental health clinics in Brisbane, Australia. METHOD: Individual semi-structured interviews were conducted with a convenience sample of patients. Interviews were audio-recorded and transcribed professionally. The authors conducted an inductive thematic analysis, attending to participant vulnerability and reflexivity. RESULTS: Sixteen interviews were conducted by one author (RW), with an average duration of 29 minutes. Three overarching themes were identified: being heard, being known, and being safe. Participants greatly valued 'good GPs' who were able to detect early signs of relapse, and with whom they came to feel heard, known, and safe over time. Experiences of perfunctory, hurried care and avoidance of mental health issues were also reported. Many participants were uncertain whether GP training in mental health was sufficient to keep them safe. Patients may suspect GPs who predominantly engage with their physical health to have negative attitudes to mental illness. CONCLUSION: Some GPs play central roles in patients' mental health care. Barriers for others need further exploration, and may include time, confidence, and/or expertise. Findings challenge GPs to engage more actively and effectively with these patients in their general practice consultations.

Heliox for croup in children.

BACKGROUND: Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (the benefits of which are often delayed) and nebulised epinephrine (adrenaline) (the benefits of which may be short-lived and which can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation. A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress. This review updates versions published in 2010, 2013, and 2018. OBJECTIVES: To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation. SEARCH METHODS: We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, on 15 April 2021. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 15 April 2021. We contacted the British Oxygen Company, a leading supplier of heliox. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo, no treatment, or any active intervention(s) in children with croup. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Data that could not be pooled for statistical analysis were reported descriptively. MAIN RESULTS: We included 3 RCTs involving a total of 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months, and all studies were conducted in emergency departments. Two studies were conducted in the USA and one in Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study because of its open-label design. We did not identify any new trials for this 2021 update. One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70) (Westley croup score, scale range 0 to 16). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low certainty, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported. In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve Taussig croup scores (scale range 0 to 15) at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -1.56 to 0.16). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be a difference in hospitalisation rates between groups (odds ratio 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to imprecision and high risk of bias related to an open-label design. Information on heart rate and intubation was not reported. In the third study, 29 children with moderate to severe croup all received continuous cool mist and intramuscular dexamethasone (0.6 mg/kg). They were then randomised to receive either heliox (given as a mixture of 70% helium and 30% oxygen) plus one to two doses of nebulised saline or 100% oxygen plus nebulised epinephrine (adrenaline), with gas therapy administered continuously for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may result in little or no difference overall using repeated-measures analysis. We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported. The included studies did not report on adverse events, intensive care admissions, or parental anxiety. We could not pool the available data because each comparison included data from only one study. AUTHORS' CONCLUSIONS: Given the very limited available evidence, uncertainty remains regarding the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate croup treated with dexamethasone. The effect of heliox may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.

Flags for seeking help: making supervisor expectations of general practice trainee help-seeking explicit.

Timely supervisor input into patient care plays a key role in ensuring the safety of patients under the care of general practice trainees. Current models of clinical supervision for trainees in both hospital and general practice training have, however, been criticised for placing too much onus on the trainee to request assistance, despite the many known barriers for trainees to do so. An important barrier to general practice trainee help-seeking is trainee uncertainty about when and how their clinical supervisor expects them to seek this assistance. We introduce a tool, 'Flags for Seeking Help', which was modified from an existing checklist, to assist supervisors to tailor their input to the care of their trainee's patients. The tool aims to make supervisor expectations of trainees explicit, including when trainees should request assistance during consultations (rather than defer this until more convenient opportunities) and when this assistance should be face-to-face (rather than by phone or messaging systems). Our aim is to reduce the barriers for trainees to request in-consultation and face-to-face supervision, in particular, when it is indicated. We outline the evidence which informed the development of the tool, and present some preliminary findings from a pilot in Australian general practice training.

Getting good help: a guide for reflection, debriefing and feedback conversations about in-consultation supervision.

Timely supervisor input to the care of their trainees' patients plays a key role in ensuring the safety of patients under the care of general practice trainees. Supervisor responses to trainee calls for assistance are also important for trainee learning and professional identity formation. The in-consultation supervisory encounter in general practice training is, however, a complex social space with multiple trainee, supervisor and patient agendas. Trainee requests for assistance during their consultations are known to present general practitioner supervisors with a number of challenges. From the trainee's perspective, a safe learning environment is essential during these supervisory interactions. A number of factors may act as barriers to, or reduce the usefulness of, in-consultation assistance in particular, resulting in trainees being less likely to seek such assistance on future occasions. It is therefore important to improve both trainee and supervisor skills in safe, effective and efficient in-consultation supervision. Making time for trainee and supervisor conversations about their help-seeking and help provision may uncover opportunities for improving skills, aligning agendas and enhancing outcomes. Finding time for debriefing, reflection and effective feedback conversations may be challenging, however, and opportunities for trainees to provide feedback to their supervisors are known to be particularly limited. We introduce a Debriefing, Reflection and Feedback Guide which is designed to prompt reflection, and structure effective and efficient debriefing and reciprocal feedback conversations. We outline the evidence which informed the development of the Guides, and present some preliminary findings from a pilot in Australian general practice training.

Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME): a stepped wedge, cluster randomised controlled trial.

OBJECTIVE: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. DESIGN, SETTING: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. PARTICIPANTS: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 - 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. INTERVENTION: Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. MAJOR OUTCOMES: Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. RESULTS: By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52-1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22-0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48-0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit-cost ratio of 31:1. CONCLUSION: A collaborative pharmacist-GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.

Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and 'patient entrustment' (patient confidence in the trainee's clinical management). Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.

Good help: a model for providing in-consultation supervision of general practice trainees.

Timely clinical supervision of trainee consultations plays a key role in ensuring the safety of patients under the care of general practice trainees, and in trainee learning and professional development. Trainee requests for assistance during their consultations present supervisors with a number of challenges, however, and a number of factors act as barriers to, or reduce the utility of, this in-consultation assistance from the trainee's perspective. Face-to-face supervision in the presence of the patient presents particular challenges and opportunities. It is important to address barriers to trainee help-seeking and improve both trainee and supervisor skills in promoting safe, effective and efficient in-consultation supervision. We introduce a model (ß-LACTAM) to assist supervisors in planning and delivering their face-to-face in-consultation supervision. The recent evidence which informed the development of this model is outlined, and some preliminary findings from a pilot of ß-LACTAM in Australian general practice training are presented.