Family medicine trainees’ clinical experience of chronic disease during training: a cross-sectional analysis from the registrars’ clinical encounters in training study

Abstract

BackgroundA 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.MethodsA 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.ResultsOf 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.ConclusionsTrainees 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.

Referrals to dietitians/nutritionists: A cross‐sectional analysis of Australian GP registrars’ clinical practice

“…This level of registrar engagement has not always been evident in other ReCEnT analyses. Analyses of continuity of care in registrars’ consultations, and of consultations with older patients and patients with chronic disease, have suggested limited therapeutic engagement in these areas . This analysis’ finding of a non‐significant trend for older patient age being associated with less dietitian/nutritionist referral than middle‐aged patients (despite increasing diet‐related morbidity with age) may reflect a general lack of engagement with the management of older patients, being evident also in diet‐related aspects of health.…”

“…They are entering practice and establishing future clinical behaviour at a time when the multidisciplinary team approach in general practice is becoming well‐accepted. A study of Australian GP registrars found that, compared to their established GP colleagues, a considerably smaller proportion (30%) of consultations included a chronic disease . However, there are no data on registrar dietetic referrals.…”

“…A study of Australian GP registrars found that, compared to their established GP colleagues, a considerably smaller proportion (30%) of consultations included a chronic disease. 18 However, there are no data on registrar dietetic referrals. The present study aimed to fill this evidence gap and describe the referral patterns of GP registrars to dietitians/nutritionists.…”

Older patients' consultations in an apprenticeship model‐based general practice training program: A cross‐sectional study

“…Patient‐based interview and survey data suggest that older patients may treat GPR consultations as a stop‐gap measure, for example for a prescription repeat, until they can consult their regular GP to address management concerns . In addition, it appears that patients’ desire to keep chronic disease management with their regular GP increases with the complexity of older patients’ health problems , supported by data demonstrating reduced rates of consultation between GPRs and patients with chronic disease in comparison with established GPs .…”

Exploring opportunities for general practice registrars to manage older patients with chronic disease: A qualitative study

“…However, the findings accord with themes of trust and continuity of care from other Australian studies. 2,4,19,24 Thus, the study offers insights into the challenges for a shared-care approach to aged care management in general practice.…”