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:Little is known about how didactic online learning materials curated by general practice faculty influence medical student impressions of general practice. METHOD:Individual interviews and focus group discussions with third- and fourth-year University of Queensland medical students, who had completed their general practice placements, explored student engagement with course materials, and impressions of general practice. Overarching themes were determined by constantly comparing theoretical memos with original data and descriptive codes. RESULTS:Student decisions whether to use materials were based on perceptions of examinability, efficiency, relevance to their placement and teaching from other specialities. Guidelines (although useful for learning) conveyed the impression that general practice was more algorithm-driven, 'prescriptive' and defensive than other specialities, reducing its intellectual challenge and attractiveness. DISCUSSION:Online learning materials contribute to student impressions of general practice. Faculty should signpost the value-add of general practice knowledge, anticipate apparent misalignment between observed practice and formal guidelines and include other learning materials that better convey the clinical acumen of general practice work.

OBJECTIVES:Frequency of general practitioners' (GPs') antibiotic prescribing for acute, self-limiting respiratory tract infections (aRTIs) is high. The practice environment and culture influence the clinical behaviour, including prescribing behaviour, of GP specialist vocational trainees (registrars). We aimed to assess inter-practice variability in registrars' antibiotic prescribing. DESIGN:This was a cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study, from 2010 to 2020. SETTING:ReCEnT documents registrars' clinical experiences and behaviours. Before 2016, 5 of 17 Australian training regions participated in ReCEnT. From 2016, three of nine regions (~40% of Australian registrars) participated. PARTICIPANTS:3210 registrars (response rate 91.8%) from 1286 training practices contributed to the analysis. OUTCOME MEASURES:The outcomes were prescription of an antibiotic for new diagnoses of (1) all aRTIs and (2) acute bronchitis diagnoses specifically. Prescribing percentages were calculated at the training practice level. Intraclass correlation coefficients (ICCs) were used to measure the ratio of interpractice variation to total variance. Median ORs (MORs) were also estimated to quantify interpractice variability. RESULTS:Practice-level antibiotic prescribing percentages ranged from 0% to 100% for both aRTIs and acute bronchitis diagnoses in the primary analysis. ICCs for aRTI prescribing were 0.08 (unadjusted) and 0.02 (adjusted). For acute bronchitis, ICCs were 0.10 (unadjusted) and 0.05 (adjusted). MORs were 1.66 (unadjusted) and 1.32 (adjusted) for aRTIs. MORs for acute bronchitis were 1.80 (unadjusted) and 1.53 (adjusted). This indicates a marked variation in the odds of a patient receiving antibiotics for an aRTI if randomly attending different practices. CONCLUSIONS:There was considerable interpractice variation in registrars' antibiotic prescribing frequencies. Further research is required to examine the factors accounting for this variation and to develop practice-level interventions to reduce antibiotic prescribing in high-prescribing practices.

Objectives To determine the use, frequency and factors linked to the use of any electronic point of care resources (ePOC resources) used by early-career general practitioners (GPs in training, otherwise known as GP residents or registrars) during consultations; and the frequency, and factors linked to the use of evidence-based clinical summaries.Design Cross-sectional analysis of data collected as part of the Registrar Clinical Encounters in Training (ReCEnT) project from 2018 to 2022. Every 6 months, GP trainees record 60 consecutive consultations, including information about their use of resources.Setting Australian training general practices.Participants 3024 GP trainees in community-based vocational training.Primary and secondary outcome measures The primary outcome was the use of ePOC resources, and the secondary outcome was the use of evidence-based ePOC summaries.Results A total of 3024 GP trainees accessed electronic resources during patient encounters for 67 651/628 855 (10.8%) of diagnoses/problems. Use of ePOC resources increased 4% per year over the study period. Therapeutic Guidelines was accessed most often (27 435/79 536, 34.7% of all ePOC use) followed by Australian Medicines Handbook (7507, 9.4%) and HealthPathways (6965, 8.7%). Various factors were associated with increased use of ePOC resources, including increasing patient age, diagnosis/problem type, increasing years of experience prior to GP training and stage of training. GP trainees rarely accessed dedicated evidence-based clinical summaries.Conclusions Australian GP trainees use a range of resources to answer their clinical questions, mostly from Therapeutic Guidelines and prescribing compendiums, but also system specific resources that are free to access.

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). Key message What is already known on this topic- Frequent performance of 'Questionable' clinical activities-activities more likely to cause harm than good or whose benefit is disproportionately low compared with its cost-can be seen a marker of the quality of health care delivery and clinical competence. Summative medical licensure/certification examination performance should reflect clinically important attributes of the candidate and provide confidence of future patient safety. What this study adds- This study demonstrates that the Royal Australian College of General Practitioners' (RACGPs') summative examination performance reflects clinical performance as assessed by a measure of 'questionable' actions in clinical practice. Performance on all three individual examination components-Applied Knowledge Test (a multiple-choice examination), Key Features Problem (a short answer plus multiple responses selection examination), and Objective Structured Clinical Exam (a clinical skills station examination), plus pass/fail status-was predicted by 'questionable' clinical practice. How this study might affect research, practice or policy- The findings provide evidence for the validity of the RACGP Fellowship examination and similar licensure/certification examinations.

BACKGROUND:The pace of new medical evidence is rapidly increasing. A modern doctor needs skills to access high-quality and up-to-date information to provide healthcare. Information seeking is often done at the point of care due to time constraints and because most consultations are conducted with the doctor and patient in the same space. There are benefits to accessing information during the consultation, and navigating this successfully requires skill.OBJECTIVE:Based on interviews with patients, this article aims to provide an updated practical approach for clinicians accessing reputable and reliable information with patients during consultations.DISCUSSION:Accessing information at the point of care is now an important clinical skill for clinicians; however, patients view this as a communication skill. Successful access and use of information can build trust through communication, transparency and actively involving the patient.

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).

Objective To explore patient perceptions regarding doctors’ information seeking during consultations.Design and setting Qualitative interviews with participants from six general practice waiting rooms in South East Queensland, Australia. Participants were asked about their experiences and opinions, and to comment on short videos of simulated consultations in which a doctor sought information. The interviews were analysed through a process of iterative thematic analysis using the framework of Braun and Clarke.Participants The 16 participants were purposively sampled including 5 men and 11 women from a diverse range of educational and age groups.Results How a doctor’s need to look up information impacted patient impressions of competence and trust was an overarching theme. The four dominant themes include: the trust a patient has in the doctor before the consultation, whether the doctor is expected to know the answer to a question without searching, has the doctor added value to the consultation by searching and the consultation skills used in the process.Conclusions Patient trust is fundamental to positive perceptions of general practitioners’ information seeking at the point-of-care. Communication is key to building this trust. Understanding the patient’s agenda, listening, assessing thoroughly and being honest and transparent about the need to seek information all contribute to a positive experience.

Tracing groundwater flow is of vital importance for managing water resources and understanding the natural water cycle. However, it is a challenge to make accurate measurements of groundwater flow due to its extremely low velocity. A new electromagnetic flowmeter has been developed to conduct non-invasive groundwater flow velocity measurements. In the setup, a customized trapezoidal current source was connected to a 1 m $\times $ 1 m square coil to generate a strong vertical magnetic field. Two electrodes were used to sense the potential difference caused by water flowing through the magnetic field. A simulation has been developed based on Faraday’s law to evaluate the flow signal under an idealized condition. Two different lab environments have been built for testing the device: an artificial mini-aquifer and a rolling gantry. The measurements show that the flow signal, in practice, generated by the slow-moving water was orders of magnitude smaller than the inductive and capacitive interferences in the system. A linear signal processing model has been developed, allowing the flow signal to be extracted from the measured results. The results show good agreement with simulation and a strong correlation between the flow speed and the processed flow signal, having an $R^{2}$ coefficient of 0.94.

Background Medical boards and healthcare providers internationally are coming under increasing pressure to attract international medical graduates (IMGs) and overseas trained doctors (OTDs) to cope with predicted general practice (GP) doctor shortages. Various pathways to registration are made available for this purpose. There is very little understanding of the effects of different training pathways to licensing and registration on the ability of IMGs and OTDs, as well as locally trained doctors, to acquire the desirable professional skills deemed necessary for working effectively in the primary care sector. Methods Feedback from patients was collected at the end of their scheduled consultation with their doctor using a questionnaire consisting of 13 Likert scale items that asked them to rate their experience of the consultation. Feedback was obtained for doctors going through the Royal Australian College of General Practice (RACGP) Practice Experience Program (PEP) and the Australian General Practice Training Program (AGPT), with the former intended primarily for IMGs and OTDs, and the latter for local medical graduates including from New Zealand. Patient feedback was also obtained for patients visiting already Fellowed and experienced GPs for comparative purposes, resulting in data for three groups of doctors (two trainee, one already Fellowed). Rater consistency and agreement measures, analysis of variance, principal component analysis, t-tests and psychometric network analysis were undertaken between and within groups to identify similarities and differences in patient experience and professionalism of doctors. Results There was a small but significant difference in average patient raw scores given to PEP and AGPT doctors (90.25, 90.97%), with the highest scores for 'Respect shown' (92.24, 93.15%) and the lowest for 'Reassurance' 89.38, 89.84%). Male patients gave lower scores (89.56%) than female patients (91.23%) for both groups of doctors. In comparison, patients gave experienced GPs an average 91.38% score, with male patients giving a lower average score than female patients (90.62, 91.93%). Two components were found in the patient data (interpersonal communication, caring/empathy) that account for over 80% of the variance. When patient scores were aggregated by doctor, the average PEP and AGPT doctor scores received were 90.27 and 90.99%, in comparison to the average experienced GP score of 91.43%. Network analysis revealed differences in the connectedness of items between these two groups as well as in comparison with experienced GPs, suggesting that PEP doctors' skills are less cohesively developed in the areas of listening ability, explaining and providing reassurance. Conclusions The small but statistically significant differences between doctor groups reported in this preliminary study are supplemented by percentile analysis, network analysis and principal component analysis to identify areas for further exploration and study. There is scope for improving the integration of interpersonal communication skills of GPs in Training with their caring and empathy skills, when compared with experienced GPs as a benchmark. Suggestions are made for enhancing professional skills from a patients' perspective in future training programs.

Background Multisource feedback is an evidence-based and validated tool used to provide clinicians, including those in training, feedback on their professional and interpersonal skills. Multisource feedback is mandatory for participants in the Royal Australian College of General Practitioners Practice Experience Program and for some Australian General Practice Training Registrars. Given the recency of the Practice Experience Program, there are currently no benchmarks available for comparison within the program and to other comparable cohorts including doctors in the Australian General Practice Training program. The aim of this study is to evaluate and compare colleague feedback within and across General Practice trainee cohorts. Methods Colleague feedback, from multisource feedback of Practice Experience Program participants and Australian General Practice Training Registrars, collected between January 2018 and April 2020, was compared to identify similarities and differences. Analyses entailed descriptive statistics, between and within groups rater consistency and agreement measures, principal component analysis, t-tests, analysis of variance, and psychometric network analysis. Results Colleague ratings of Practice Experience Program participants (overall average 88.58%) were lower than for Registrars (89.08%), although this difference was not significant. ‘Communication with patients’ was rated significantly lower for Practice Experience Program participants (2.13%) while this group was rated significantly better for their ‘Ability to say no’ (1.78%). Psychometric network analyses showed stronger linkages between items making up the behavioural component (compared to the items of the performance and self-management components, as found by principal component analysis) for Practice Experience Program participants as compared to Registrars. Practice Experience Program participants were stronger in clinical knowledge and skills as well as confidentiality, while Registrars were stronger in communicating with patients, managing their own stress, and in their management and leadership skills. Conclusions The multisource feedback scores of doctors undertaking the Practice Experience Program suggests that, while all mean values are ‘very good’ to ‘excellent’, there are areas for improvement. The linkages between skills suggests that Practice Experience Program doctors’ skills are somewhat isolated and have yet to fully synthesise. We now have a better understanding of how different groups of General Practitioners in training compare with respect to professional and interpersonal skills. Based on the demonstrated differences, the Practice Experience Program might benefit from the addition of educational activities to target the less developed skills.

This paper determines the scale factor for an electromagnetic groundwater flowmeter using an air-cored square pancake coil as the electromagnet. It also proposes the use of an array of electrodes to provide a better estimate of the average water speed between the electrodes.

The postpartum period is a time when physical, psychological and social changes occur. Health professional contact in the first month following birth may contribute to a smoother transition, help prevent and manage infant and maternal complications and reduce health systems' expenditure. The aim of this systematic review was to assess the effect of face-to-face health professional contact with postpartum women within the first four weeks following hospital discharge on maternal and infant health outcomes. Fifteen controlled trial reports that included 8332 women were retrieved after searching databases and reference lists of relevant trials and reviews. Although the evidence was of moderate or low quality and the effect size was small, this review suggests that at least one health professional contact within the first 4 weeks postpartum has the potential to reduce the number of women who stop breastfeeding within the first 4-6 weeks postpartum (Risk Ratio 0.86 (95% Confidence Interval 0.75-0.99)) and the number of women who cease exclusive breastfeeding by 4-6 weeks (Risk Ratio 0.84 (95% Confidence Interval 0.71-0.99)) and 6 months (Risk Ratio 0.88 (95% Confidence Interval 0.81-0.96). There was no evidence that one form of health professional contact was superior to any other. There was insufficient evidence to show that health professional contact in the first month postpartum, at a routine or universal level, had an impact on other aspects of maternal and infant health, including non-urgent or urgent use of health services.

A return-to-zero, bipolar, trapezoidal current generator for driving the coil of a prototype electromagnetic groundwater flowmeter is described. Operation of the circuit, which employs a laboratory DC power source, a MOSFET H-bridge, some ancillary components and a microcontroller-based control system, is analyzed, simulated and practically demonstrated. Although the circuit can produce acceptable results, we show that it is sensitive to component tolerances and timing jitter and is inherently limited in realizable efficiency.

The signals measured by electromagnetic flowmeters are corrupted by 1/f noise from the electrodes and interference from changing electric and magnetic fields when driving the electromagnet. The effect of this interference can be mitigated using system identification using a generalized linear least squares approach and a suitable model. However, this approach fails for linear models when the level of interference is strong compared to the desired flow signal. This is due to non-linearities in the behaviour of the measurement electrodes. In this paper we show that the non-linear behaviour can be mitigated using non-linear system identification procedures. Specifically, a variant of the NARMAX algorithm was employed to determine a non-linear system model. Experimental results show that this approach produces an improved and more consistent estimation of the flow signal.

Aim This study explores the General Practice (GP) experience of Gestational Diabetes Mellitus (GDM). Much has been written about patient perspectives, yet little is known about the GP perspective at initial diagnosis and management. GDM is increasingly managed in the secondary and tertiary sector, the confidence of GPs and their role in ongoing care has not been examined. Given GDM’s poor follow up rates, all aspects of the patient journey warrant close examination. Methods Through purposive and snowball sampling, we conducted semi-structured interviews with GPs in Brisbane, Australia between April and October 2018. Data collection, until saturation, and analysis were concurrent, and the Leximancer analysis tool assisted with content analysis and suggestion of themes. Results Dominant themes include uncertainty/urgency and feeling under-utilised. GPs have a pragmatic approach in the face of uncertainty, and adopt one of several strategies to meet patient needs. A key issue that may impact on long term follow up and high quality GP-patient relationships is concern about the patient being ‘taken away’ by the hospital. Communication with the hospital is generally perceived as poor. Conclusions The experience of GPs in the initial diagnosis and management of GDM may assist in improving GDM follow up.

Nutrients leaching through groundwater are one contributor to waterway contamination. Guiding land use decisions to reduce the impact on water resources requires accurate knowledge of the flow of groundwater. Currently, measurements from monitored wells are used to tune models of this flow. However, there are few wells available and so the data is sparse. An electromagnetic flowmeter has been proposed to simplify the measurement of groundwater flow and provide data to generate more robust models. Although based on a sensing technique that has been widely used for measurement of flow in pipes, the slow movement of groundwater results in small signals subject to significant interference. This paper presents some initial laboratory results from a prototype electromagnetic flowmeter showing that there is a tradeoff between noise and self-interference reduction.