BackgroundCellulitis is a common bacterial skin infection usually requiring antibiotic treatment. Accurate diagnosis and management are crucial for patient prognosis and antibiotic stewardship. Phenoxymethylpenicillin is usually the recommended first-line antibiotic for suspected streptococcal nonpurulent cellulitis. This study investigated antibiotic prescribing patterns and temporal trends for new diagnoses of cellulitis by Australian general practice registrars (speciality trainees in general practice [family medicine]).MethodsAnalyses of the Registrar Clinical Encounters in Training (ReCEnT) study utilised registrars' 2010-2021 consultation data involving new diagnoses of cellulitis. The proportion of consultations involving the prescription of antibiotics was calculated. Univariable and multivariable logistic regression examined longitudinal changes in the prescription of the two most prescribed antibiotics (cefalexin vs. flucloxacillin/dicloxacillin), adjusted for patient, registrar, practice and consultation factors.ResultsA total of 3852 registrars provided data. Of 2708 new diagnoses of cellulitis, flucloxacillin/dicloxacillin was most commonly prescribed (n = 1209; 43.6% [95% CI: 41.8, 45.5), followed by cefalexin (n = 1191; 43.0% [95% CI: 41.1, 44.9]). Phenoxymethylpenicillin was prescribed in 0.6% of cases [95% CI: 0.3, 0.9]. Cephalexin prescription relative to flucloxacillin/dicloxacillin did not change over the 12-year period (OR 0.99 per year [95% CI: 0.96, 1.03]). Prescription of cefalexin, compared to flucloxacillin/dicloxacillin, was associated with (compared to the age group 25-44 years) ages less than 5 years (OR 2.75 [95% CI: 1.70, 4.43], 5-14 (OR 2.51 [95% CI: 1.63, 3.89]) and 65 years and older (OR 1.51 [95% CI: 1.15, 1.99]). Cefalexin prescription was less likely when registrars sought in-consultation information from 'Therapeutic Guidelines (Antibiotic)' guidelines (OR 0.58 [95% CI: 0.43, 0.80]), supervisors (OR 0.69 [95% CI: 0.51, 0.94]) or other sources (OR 0.64 [95% CI: 0.43, 0.96]).ConclusionsPhenoxymethylpenicillin was prescribed in only 0.6% of presentations, whereas cefalexin and flucloxacillin/dicloxacillin accounted for over 86% of prescriptions. This may reflect a lack of guideline specificity regarding first-line treatment options and/or registrars' aetiological diagnostic uncertainty. Prescribing patterns remained relatively stable over time.

Fellowship examinations in Australian vocational general practice training assess competency for unsupervised practice. Early identification of trainees at risk of failing these summative examinations facilitates pro-active remediation. This study aimed to explore the utility of formative pre-general practice assessments (PGAs), undertaken at the commencement of training, for predicting final summative examination performance. This was a retrospective cohort study. The PGAs included a written, short-answer, five-case Key Feature Problems test (‘PGA-KFP’) and an Objective Structured Clinical Examination (‘PGA-OSCE’). Multivariable regression was used to examine the relationship between these PGAs and standardized scores on first-attempts at three summative fellowship examinations (an Applied Knowledge Test (‘Fellowship-AKT’), a KFP (‘Fellowship-KFP’) and an OSCE (‘Fellowship-OSCE’); and passing all three (versus failing at least one) examination on first attempt. Registrar demographics and training-related factors were included as covariates. Higher PGA-KFP and PGA-OSCE scores were univariably associated with higher Fellowship-AKT, Fellowship-KFP, and Fellowship-OSCE scores (all p-values ≤ 0.002) and with passing all three examinations on first attempt (p < 0.006). On multivariable analyses, higher PGA-KFP and PGA-OSCE scores were significantly associated with higher Fellowship-AKT, Fellowship-KFP (p values ≤ 0.016) but not Fellowship-OSCE scores. Higher PGA-KFP scores were also predictive of passing all three Fellowship exams on first attempt (p < 0.001). This study found intensive formative assessments conducted at the commencement of training to be predictive of final fellowship examination performance in an apprenticeship-based model of general practice training. This suggests utility of these assessments for early-identification of trainees in need of proactive remediation both in Australia and internationally. Further research is required to explore predictive utility of less resource-intensive PGAs.

Objective To investigate the frequency and temporal trends in Australian early-career general practitioners (registrars) accessing point-of-care resources (POCR) when managing paediatric asthma.Design A longitudinal analysis (2010–2019) nested within the Registrar Clinical Encounters in Training project of registrars’ in-consultation practice. The outcome factor in univariable and multivariable mixed effects logistic regression analyses was whether POCR was accessed for paediatric asthma problems, with year as the independent variable of interest. Further analyses compared trends (2010–2019) in asthma problem POCR use with non-asthma problem POCR use.Setting Australian community training general practices.Participants 2834 Australian general practice registrars (trainees) (participation rate 92.2%).Result POCR use was greater for asthma (15%) than for non-asthma problems (12.6%). The temporal increase in POCR use for paediatric asthma (OR for POCR use 1.15 per year (95% CI 1.07 to 1.24)) was greater than that for non-asthma problems (OR of 1.11 per year (95% CI 1.09 to 1.14)). This difference in rates of increase in POCR of paediatric asthma and non-asthma problems was not statistically significant.Conclusion There are multiple possible reasons for the increasing use of POCR in paediatric asthma. This trend may reflect increasing focus on evidence-based asthma care and increasing access to high-quality asthma management online POCR available within Australia. Alternatively, paediatric asthma could represent an area of increasing clinical challenge and possible educational need for early-career general practitioners. Further research exploring the underlying reasons for the increasing POCR use in paediatric asthma is warranted.

BACKGROUND AND OBJECTIVES:Validity of workplace-based assessments (WBA) is important, yet rare in general practice. The General Practice Registrar Competency Assessment Grid (GPR‑CAG) assesses registrar in‑consultation performance, as observed during external clinical teaching visits. GPR‑CAG content validity and initial internal consistency is established. This study aimed to confirm the GPR‑CAG factor structure. METHOD:Confirmatory factor analysis was conducted using factors and items from an exploratory factor analysis. Separate analyses were conducted for Term 1 (GPT1; 16 items) and Term 2 (GPT2; 27 items) registrar data (n=827 and n=796, respectively). RESULTS:Analyses supported the existing GPT1 GPR-CAG factor structure, with fit indices showing good fit of the data to the model and most factor loadings being moderate‑to-high. For GPT2, a single model change was strongly supported, after which model fit was good, the factor structure coherent and most item loadings moderate-to-high. DISCUSSION:This study supports the GPR-CAG as a psychometrically robust, evidence-based WBA.

IntroductionAntimicrobial resistance is a global emergency related to overprescribing of antibiotics. Few studies have explored how prescribing behaviours may change as the consequence of changing resistance. Understanding how contextual factors influence antibiotic prescribing will facilitate improved communication strategies to promote appropriate antibiotic prescribing. We aimed to develop and conduct a discrete choice experiment (DCE) to measure how contextual factors influence intended antibiotic prescribing of general practitioner (GP) registrars.MethodsFactors included as attributes in the DCE were level of antibiotic resistance, requirement for an authority to prescribe, existence of a Practice Incentives Program (PIP) for low prescribing and supervisor support for low prescribing. The survey was administered in an online format for GP registrars undergoing training between 2020 and 2021. Regression analysis using a conditional logit model with interaction effects was used on the basis of the assumptions of independence of irrelevant alternatives, independence of error terms and no preference heterogeneity.ResultsIn total, 617 unique respondents answered at least one choice set question. Respondents showed significant preference for avoiding prescribing antibiotics when antibiotic resistance was 25-35% or 40-60% compared with 5-8%. There was also a significant preference for avoiding prescribing when an authority to prescribe was required, or when there was supervisory support of low antibiotic prescribing. In the main effects analysis, respondents were significantly less likely to choose a prescribing option if there was a PIP; however, when interaction effects were included in the regression analysis there was a significant interaction between PIP and resistance rates, but the preference weights for PIP was no longer significant.ConclusionsKnowledge about community resistance impacts the stated intention of GP registrars to prescribe antibiotics. The use of the DCE may have made it possible to determine factors influencing prescribing that would not be detected using other survey methods. These findings provide guidance for producing, explaining and communicating issues regarding antibiotic prescribing to GP registrars.

In Australia's apprenticeship-style model of general practice training, experienced general practitioner supervisors oversee individual registrars' training in accredited training practices. In addition to providing formal in-practice education to registrars, supervisors have informal teaching and clinical support functions, including being called in by registrars seeking in-consultation advice/assistance. These ad hoc encounters are important learning opportunities but can be challenging to negotiate in the busy clinical environment and require registrars' assistance-seeking to be judiciously managed by supervisors. This study aimed to estimate variability between training practices in relation to registrars having recourse to supervisory in-consultation advice/assistance. The study used a cross-sectional analysis from the Registrar Clinical Encounters in Training project, an ongoing prospective cohort study of Australian registrars' in-consultation clinical and educational practise. Analyses used 2010 to 2021 data with outcome factor 'supervisor provided advice/assistance'. Inter-practice variability was estimated by intra-class correlation coefficients and median odds ratios within a Bayesian modelling framework. 4642 registrars contributed details of 1,026,330 problems/diagnoses 69,114 (6.73%; 95% confidence interval: 6.69-6.78%) involved in-consultation supervisory advice/assistance. On multivariable analysis, adjusting for confounding, the intra-class correlation coefficient for provision of supervisory advice/assistance was 0.043 (95% credible interval: 0.038-0.049), the median odds ratio was 1.523 (95% credible interval: 1.480-1.569). This analysis can be interpreted as a registrar randomly moving from one training practice to another will have a median of 52% increase in the odds of a registrar seeking (and a supervisor providing) in-consultation advice/assistance for a particular problem/diagnosis. These findings raise policy and practice questions about developing a consistent response to ad hoc supervisory encounters.

Background Inappropriate antibiotic prescription for self-limiting respiratory tract infections (RTIs) by general practitioner (GP) registrars (trainees) is less common than by established GPs but still exceeds evidence-based benchmarks. A 2014 face-to-face educational intervention for registrars and supervisors reduced registrars’ acute bronchitis antibiotic prescription by 16% (absolute reduction). We aimed to establish the efficacy of an updated registrar/supervisor RTI-management intervention (delivered at distance) on antibiotic prescribing. Methods A non-randomized trial using a non-equivalent control-group nested within the ReCEnT cohort study. The intervention included online educational modules, registrar and supervisor webinars, and materials for registrar-supervisor in-practice educational sessions, and focussed on acute bronchitis as an exemplar RTI. The theoretical underpinning was the ‘capability, opportunity, and motivation’ (COM-B) framework. The intervention was delivered to registrars and supervisors of one large educational/training organization annually from mid-2021, with pre-intervention period from 2017, and with postintervention period ending 2023. Two other educational/training organizations served as controls. The primary outcome was antibiotics prescribed for acute bronchitis. Analyses used multivariable logistic regression with predictors of interest: time (before/after intervention), treatment group, and an interaction term for time-by-treatment group, adjusted for potential confounders. The interaction term P-value was used to infer statistical significance of the intervention effect. Results Of 4612 acute bronchitis presentations, 70% were prescribed antibiotics. There was a 6.9% absolute reduction (adjusted) of prescribing in the intervention-group compared with the control-group. This was not statistically significant (Pinteraction = .22). Conclusions Failure to find a significant effect on prescribing suggests difficulties with scalability of this (and similar educational) innovations.

BACKGROUND AND OBJECTIVES:Evidence-based prescribing for heavy menstrual bleeding (HMB) can improve quality of life, iron deficiency and anaemia. Tranexamic acid (TXA) is more effective than oral hormonal medications (OHMs). This study aimed to establish temporal trends (2010-23) in TXA prescribing for HMB by Australian general practice registrars. METHOD:Cross-sectional analyses were conducted within an ongoing inception cohort study (Registrar Clinical Encounters in Training [ReCEnT]), using multivariable mixed logistic regression models. RESULTS:In 4717 registrars (response rate 93.4%), adjusted odds of prescribing TXA for HMB increased by 12% annually (odds ratio [OR] 1.12, 95% confidence interval [CI]: 1.04-1.20], P=0.004), and 18% annually when compared to OHMs (OR 1.18, 95% CI: 1.03-1.36, P=0.019). General practice registrars who consulted their supervisor were less likely to prescribe TXA compared to OHMs (OR 0.36, 95% CI: 0.14-0.92, P=0.034). DISCUSSION:Registrars' increasing TXA prescribing suggests an appropriate response to evidence. Supervisors may be slower to implement this evidence, warranting further investigation to inform evidence-based prescribing strategies.

Direct observation, workplace-based assessments (WBAs) are a fundamental component of competency-based postgraduate medical education. In Australian general practice vocational training, external clinical teaching visits (ECTVs) are key observation-based WBAs. Traditionally, ECTVs are conducted face-to-face, but the COVID-19 pandemic saw the development and implementation of remote ECTV modalities. It remains unknown if perceived educational utility of remote ECTVs differs from traditional face-to-face ECTVs. This study explored the educational utility of ECTVs, including face-to-face and remote formats. General practice trainees (‘registrars’) and external clinical teaching visitors (‘ECT visitors', who are independent experienced GP observers) each completed a cross-sectional questionnaire following individual ECTVs undertaken in 2020. Outcomes included overall educational utility of the ECTV as perceived by registrars, registrar ratings of likelihood to change their clinical practice as a result of the ECTV, registrar ratings of likelihood to change their approach to learning/training as a result of the ECTV, and overall educational utility of the ECTV as perceived by the ECT visitor. Educational utility ratings (5-point scales) were analysed descriptively. Univariable and multivariable logistic regression were employed to examine factors associated with dichotomised educational utility ratings. Response rates were 41

RATIONALE:General practice is central to older patient care provision. For GP registrars (specialist GPs in training), exposure to older patients is also vital for developing chronic disease and multimorbidity management skills. However, registrars see fewer older patients, and are less engaged with older patient care, than established GPs. AIMS AND OBJECTIVES:This study aimed to assess inter-practice variability in the proportion of older patients seen by Australian GP registrars during training. METHOD:Cross-sectional analysis from the ReCEnT study of GP registrars' clinical experiences (2010-2023). The outcome was consultation with older (65+ years) patients. Inter-practice variability was assessed with Intraclass Correlation Coefficient (ICC) and Median Odds Ratio (MOR). Outcome variance attributable to practice was estimated within the Bayesian modelling framework using a mixed-effects logistic regression with cross-classified random effects for registrar and practice. RESULTS:The analysis included 4643 registrars across 978 practices. 19% (129,659/688,281) of consultations were with older patients. The ICC was 0.15 (95% Credible Interval (CrI) [0.14, 0.17]) in a model with a random effect for practice; and, in a model adjusted for time/registrar/patient/practice variables, 0.10 (CrI [0.09, 0.11]). These values (comparable with, or higher than, reported for other general practice variables), indicate registrars' older patient clinical exposure is dependent upon the practice(s) trained in. The MOR was 2.08 (CrI [(2.00, 2.16]); and, adjusted, 1.81 (CrI [1.76, 1.87). By randomly changing practice location, the odds of a registrar's consultation being with an older patient thus approximately doubles (or, alternatively, halves) on average. CONCLUSION:The practice itself is the greatest determinant in registrars' exposure to older patients. Practice-level interventions are essential to improve registrars' in-training older patient care experience.

BACKGROUND AND OBJECTIVES:General practitioners' (GPs) specialised qualifications and upskilling in medical roles strengthen healthcare systems and improve patient outcomes. This study aimed to describe additional qualifications attained, or being undertaken, by early career GPs and establish associations of obtaining/undertaking postgraduate and post-Fellowship qualifications. METHOD:This was a questionnaire-based, cross-sectional study of early career college-Fellowed GPs in NSW/ACT, Tasmania and Eastern Victoria (New alumni Experiences of Training and independent Unsupervised Practice [NEXT-UP] study). Univariable and multivariable logistic regression analyses estimated associations of additional postgraduate/post-Fellowship qualification attainment with personal factors and factors related to their current practice and to their vocational training experience. RESULTS:Of 339 participants, 43% reported having obtained postgraduate, medically related qualifications, 23% had obtained or were undertaking post-Fellowship qualifications and 35% reported no additional qualifications. There was a strong negative association of additional qualifications with having dependent children (odds ratios 0.76 and 0.63 for postgraduate and post-Fellowship qualifications, respectively). DISCUSSION:Most early career GPs obtained or were pursuing postgraduate/post-Fellowship qualifications. A barrier to obtaining postgraduate or post-Fellowship qualifications might be having dependent children.