Common dilemmas in kids

2015

Research

Clinical exposure of interns during a general practice placement

Volume 44, No.6, 2015 Pages 393-396

Nyoli Valentine

Ian McCombe

Bruce Mugford

Background

For more than a decade, junior doctors have undertaken general practice rotations; however, little is known about the breadth of medical conditions seen. This study aims to determine the breadth of clinical presentations encountered by interns during a rota-tion.

Methods

Data were collected on all patients seen by interns at an RA-2 general practice during 2012–13. Each condition identified was compared with the Australian Curriculum Framework for Junior Doctors (ACFJD) and coded according to the International Clas-sification of Diseases 10th revision (ICD-10).

Results

Interns saw an average of 482.2 (SD = 38) patients per rotation (10.7 patients per day), 150.3 (SD = 15.4) ICD-10 codes per rota-tion and 49.8 (SD = 4.9; 57.2%) of the listed clinical symptoms and conditions in the ACFJD.

Internship is a transitional year from medical student to medical practitioner, allowing students to build on and extend their theoretical knowledge and technical skills.1 For more than a decade, interns have had the opportunity to undertake a rotation within a general practice setting.2

Studies from the United Kingdom have unanimously promoted the educational benefits of general practice rotations.3 Junior doctors interviewed have reported the experience as beneficial, enjoyable and would recommend it.3 Junior doctors working in general practice rotations had similar learning experiences to those on other rotations, including communication skills, consultation skills, awareness of illness presentation and the ability to investigate illness appropriately.4 A British national evaluation report noted that in 26 of 51 areas measured, junior doctors in general practice were judged to be more competent than a hospital-based reference group.3

In Australia, qualitative research has shown that interns perceive general practice terms as enhancing their professional growth.2 However, there has been little research done on the clinical exposure of general practice rotations. A recent literature review noted there was limited published research covering the range of skills or competencies gained by junior doctors in rural general practice.5 It is assumed interns will see a wide variety of medical conditions, as general practitioners (GPs) are responsible for providing primary care to patients of all ages, and the diversity of presentations to GPs is unparalleled in other medical specialties.6 Australian GPs need to have a good understanding of 167 problems to cover 85% of the conditions they will see most frequently.7

The aim of this pilot quantitative study was to determine the breadth of clinical presentations encountered by interns during a general practice rotation.

Methods

Ethics approval was provided by the Queen Elizabeth Hospital Human Research Ethics Committee (HREC/13/TQEHLMH/270). Interns undertaking a general practice rotation at a medical centre classified as inner regional, remoteness area 2 in the Australian standard geographical classification, during 2012 and 2013 collected data on all of the patients they encountered. The information they collected included the date of the encounter, the age of the patient, gender of the patient and patient presentation. For every clinical presentation, patients were reviewed by a supervisor in accordance with usual practice. Internal feedback from interns and from the practice showed a high level of satisfaction with this rotation.

The number and gender of patients seen, the average number of patients per day and the mean age, median age and age range of patients seen were calculated for each rotation. The number of children (<18 years) and the number of elderly patients (≥75 years) were also calculated.

The data were mapped to the Australian Curriculum Framework for Junior Doctors (ACFJD) Clinical Symptoms, Problems and Conditions and also coded against the International Classification of Diseased 10 revision (ICD-10 codes).8 The ACFJD outlines the knowledge and skills expected of junior doctors and has been developed using a collaborative, evidence-based and inclusive approach. The ACFJD is widely used in education settings across Australia.9 If the interns listed more than one condition then all conditions were mapped and coded.

Results

Table 1. Patient load and demographics (group totals)

 

Group total

Average per rotation

Number of patients

3858

482.2 (SD = 38)

Number of consulting days

362

45.3 (SD = 3.5)

Mean patients per day

N/A

10.7 (SD = 0.7)

Female patients

2272

284 (SD = 28.8; 58.9%)

Mean age

N/A

34.5 (SD = 1.6)

Number of patients <18 years

1086

135.8 (SD = 20.1; 28.2%)

Number of patients ≥75 years

204

25.5 (SD = 9.6; 5.3%)

Table 1 provides information on the patients seen by the interns as a group during the study period. Interns saw an average of 482.2 (SD = 38) patients per rotation; 284 (SD = 28.8; 59%) were female. The youngest patient seen was 6 weeks old and the oldest patient was 99 years; the mean age was 34.5 years (SD = 1.6).

Table 2. ACFJD common symptoms and signs

ACFJD common symptoms and signs

Percentage of interns who saw symptom and sign

Fever

100%

Dehydration

100%

Loss of consciousness

63%

Syncope

88%

Headache

100%

Toothache

75%

Upper airway obstruction

38%

Chest pain

100%

Breathlessness

100%

Cough

100%

Back pain

100%

Nausea and vomiting

100%

Jaundice

0

Abdominal pain

100%

Gastrointestinal bleeding

25%

Constipation

75%

Diarrhoea

100%

Dysuria or frequent micturition

100%

Oliguria and anuria

0

Pain and bleeding in early pregnancy

75%

Agitation

13%

Depression

100%

Table 2 shows the percentage of interns who saw the common symptoms and signs listed in the ACFJD. The most common clinical conditions seen were listed and the average number of times seen by each intern calculated (Table 3).

Table 3. Most common ICD-10 codes

Condition

Average number of times seen during each rotation

Acute nasopharyngitis

49

Back pain

37

Person attending for repeat prescription

25

Gastroenteritis

17

Otitis media

14

Urinary tract infection

13

Tonsillitis

10

Asthma

10

Sinusitis

9

Person consulting for investigation results

9

Contraceptive management

8

Hypertension

8

Depressive episode

7

Abdominal pain

6

Viral infection (site not specified)

6

Examination for drivers licence or issue of medical certificate

6

Soft tissue injury

5

Laceration

5

Gastro-oesophageal reflux disease

4

Ear wax

4

Tables 47 are available online only. Table 4 summarises the patients seen by interns in each of the eight rotations. Table 5 summarises the ACFJD clinical symptoms, problems and conditions, and clinical codes seen by the individual interns. Table 6 shows the ACFJD areas and clinical codes seen by the interns as a group during the study period. Interns saw an average of 49.8 (SD = 4.9; 57.2%) ACFJD clinical symptoms, problems and conditions. The least number of ACFJD conditions seen was 44 and the most was 58. Interns saw an average of 150.3 (SD = 15.4) ICD-10 clinical codes. Table 7 summarises the percentage of interns who saw the common clinical problems and conditions.

Table 4. Patient load and demographics by rotation

Rotation Number

1

2

3

4

5

6

7

8

Number of patients

485

546

451

453

505

488

504

426

Number of consulting days

46

47

44

48

47

47

46

37

Mean patients per day

10.5

11.6

10.3

9.4

10.7

10.4

11

11.5

Females, n (%)

314
(64.7)

331
(60.6)

257
(56.9)

266
(58.7)

291
(57.6)

290
(59.4)

278
(55.2)

245
(57.5)

Mean age (range)

34
(0.2–96)

34.6
(0.1–99)

36.7
(0.5–96)

34
(0.1–93)

34.8
(0.1–96)

35
(0.1–91)

31.3
(0.1–91)

35.7
(0.3–94)

Number of patients <18 years (%)

128
(26.4)

153
(28)

103
(22.8)

129
(28.5)

145
(28.7)

136
(27.9)

169
(33.5)

123
(28.9)

Number of patients ≥75 years (%)

13
(2.7)

28
(5.1)

22
(4.9)

19
(4.2)

39
(7.7)

23
(4.7)

20
(3.9)

40
(9.4)

 

Table 5. Clinical codes and ACFJD clinical symptoms, problems and conditions seen by rotation

Rotation Number

1

2

3

4

5

6

7

8

Number of ICD-10 codes

131

162

130

156

176

152

151

144

Number of ACFJD (total 87)

44
(50.6%)

52
(59.8%)

49
(56.3%)

55
(63.2%)

58
(66.7%)

45
(51.7%)

48
(55.2%)

47
(54%)

Number of ICD-10 codes in patients <18 years

50

59

47

54

71

53

64

61

Number of ICD-10 codes in patients ≥75 years

9

23

17

15

26

16

18

24

 

Table 6. Clinical codes and ACFJD clinical symptoms, problems and conditions seen (group totals)

 

Group total

Average per rotation

Number of ICD-10 codes

1202

150.3 (SD = 15.4)

Number of ACF (total 87)

398

49.8 (SD = 4.9) (57.2%)

Number of ICD-10 codes
in patients <18 years

459

57.4 (SD = 7.9)

Number of ICD-10 codes
in patients ≥75 years

148

18.5 (SD = 5.6)

 

Table 7. ACFJD common clinical problems and conditions

ACFJD common clinical problems and conditions

Percentage of interns who saw clinical condition

ACFJD common clinical problems andconditions continued

Percentage of interns who saw clinical condition

ACFJD common clinical problems and conditions continued

Percentage of interns who saw clinical condition

Non specific Febrile illness

100%

Gout

63%

Anaemia

25%

Sepsis

25%

Septic arthritis

25%

Bruising and bleeding

75%

Shock

25%

Hypertension

100%

Management of anticoagulation

75%

Anaphylaxis

25%

Heart failure

50%

Cognitive or physical disability

25%

Envenomation

63%

Ischaemic heart disease

75%

Substance abuse and dependence

100%

Diabetes mellitus

100%

Cardiac arrhythmias

13%

Psychosis

38%

Thyroid disorders

100%

Thromboembolic disease

63%

Depression

100%

Electrolyte disturbances

0

Limb ischaemia

0

Anxiety

100%

Malnutrition

13%

Leg ulcers

25%

Deliberate self harm and suicidal behaviour

0

Obesity

38%

Oral infection

100%

Paracetamol overdose

0

Red painful eye

100%

Periodontal disease

75%

BZ and opiod overdose

0

Cerebrovascular disorders

50%

Asthma

100%

Common malignancies

75%

Meningitis

0

Respitatory Infection

100%

Chemotherapy and radiothearpy side effects

25%

Seizure disorder

50%

COPD

38%

The sick child

100%

Delirium

13%

OSA

25%

Child abuse

0

Common skin rashes and infections

100%

Liver disease

13%

Domestic violence

0

Burns

63%

Acute abdomen

88%

Dementia

13%

Fractures

100%

Renal failure

25%

Functional decline or impairment

50%

Minor trauma

100%

UTI and pyelonephritis

100%

Falls

88%

Multiple Trauma

25%

Urinary incontinence and retention

25%

Elder abuse

0

Osteoarthritis

75%

Menstrual disorder

100%

Poisoning/ overdose

0

Rheumatoid Arthritis

0

STI

63%

 

 

Discussion

Interns in this pilot study were exposed to a diverse range of conditions across all age ranges. All of the interns covered at least half of the ACFJD clinical symptoms, problems and conditions curriculum in one rotation and saw in excess of 150 ICD-10 codes.

All interns saw paediatric and elderly patients throughout their rotation. Paediatric patients were commonly seen and represented 28% of patients. This is consistent with previous studies noting children aged 0–19 make up almost one-quarter (23%) of visits to general practice registrars.6 This paediatric exposure is particularly important for junior doctors, as interns and resident medical officers (RMOs) are often unable to obtain a paediatric rotation and thus gain paediatric experience. General practice rotations may be an opportunity where this educational experience can be gained. Conversely, only 5% of patients seen by interns were ≥75 years. This limitation of this general practice rotation can be covered by traditional hospital rotations where 22% of hospital separations are for patients ≥75 years.10 The mean age of patients seen was 34.5 years, which is younger than the hospital mean age.10

During this rotation, interns worked an average of 38 hours per week and did not attend on call or after hours. Despite this, interns saw an average of 48 patients per week. This is equal to other hospital rotations and previous research has noted that interns see 35–50 patients per week across various rotations.11 There are no available data on the breadth of curriculum seen in other hospital rotations for comparison with our data.

There has been little published work aligning clinical exposure with the ACFJD in general practice rotations.5 This study reviewed the clinical symptoms, problems and conditions of ACFJD and noted interns saw an average of 58% of those symptoms and conditions listed in one 10-week rotation. Interns were exposed to an average of 150 ICD-10 clinical codes. This supports work by Scallan in the UK, who noted multiple studies show pre-registration house officers are exposed to a wide variety of clinical experience, which in certain areas is superior to exposure in hospital terms.12 As reflected by the demographics of patients seen, interns saw an average of 57 ICD-10 clinical codes for paediatric patients and fewer for elderly patients.

There has been debate in Australia as to whether general practice rotations can be considered emergency terms. To achieve full registration, interns must complete a core emergency term by providing supervised experience in ‘the assessment and management of patients with acute undifferentiated illnesses, including assessment and management of acutely ill patients’.13 Being primary healthcare providers, GPs are faced with undifferentiated illness on a daily basis. It has been noted in the UK that junior doctors’ caseloads tend to lean more towards acute illness and ‘on-the-day’ patients.12 This study also reflected this phenomenon.

A recent report in South Australia reviewed a core set of emergency conditions, including abdominal pain, breathlessness and chest pain, and noted there was no significant difference between interns undertaking their emergency rotation in general practice and interns undertaking a tertiary hospital emergency rotation with regards to the number of symptoms and conditions seen.14 Although the number of high-acuity conditions seen on a regular basis for general practice interns was lower, they had a greater opportunity to have a direct role in caring for high-acuity patients.14 Furthermore, a UK study reviewed junior doctors’ self-reported confidence in managing conditions and found junior doctors were most confident in managing chest pain and shortness of breath. They were significantly less confident in managing minor complaints.15 General practice terms can help with this through exposure to multiple acute undifferentiated illnesses.

Across Australia, the number of interns commencing practice has risen by more than half, from 1531 in 2004 to 2394 in 2010.16 As a public hospital internship is guaranteed for all Commonwealth-funded medical graduates,16 general practice placements may be needed for training purposes for junior doctors. This study has shown these placements provide adequate exposure for doctors early in their career.

There were some limitations to this study. This was a pilot study with data collected from one general practice placement over 2 years. There was variability in the way each junior doctor recorded the reason for consultation, which influenced the way it was coded. For example, some junior doctors recorded viral infection, whereas other junior doctors recorded viral upper respiratory tract infection. In addition, many junior doctors only recorded one reason for visit when it is likely that multiple issues were raised during a consultation, as it is known that on average a GP deals with 1.4–8 ICD codes per consultation.17–19 These limitations are likely to underestimate the number of ICD-10 codes and ACFJD clinical symptoms seen.

Further research on general practice placements could focus on reviewing intern clinical exposure in different general practices, including comparing urban with rural. It would also be beneficial to measure the interns’ competency in managing these clinical presentations at the end of the rotation.

Implications for general practice

  • Interns are exposed to a variety of clinical conditions during a general practice rotation, despite only being in a general practice for 10 weeks.
  • Interns see more than half of the clinical signs and symptoms listed in their junior doctor curriculum during one rotation.
  • General practice placements provide invaluable opportunities for training the large numbers of junior doctors in the current Australian workforce.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.

References

  1. Medical Practitioners Board of Victoria. A Guide for Interns in Victoria. Fitzroy: Medical Practitioners Board of Victoria, 2009.
  2. Martin AA, Laurence CO, Black LE, et al. General practice placements for pre-registration junior doctors: adding value to intern education and training. Med J Aust 2007;186:346–49.
  3. Illing J, Van Zwanenberg T, Cunningham WF, et al. Preregistration house officers in general practice: review of evidence. BMJ 2003;326:1019–22.
  4. Grant J, Southgate L. Pre-registration house officer placements in general practice. (NHSE Report.) Milton Keynes: Centre for Education in Medicine, Open University, 2000.
  5. Young L, Larkins SL, Sen Gupta TK, et al. Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors. Med J Aust 2013;199:787–91.
  6. Freed GL, Spike N, Magin P, et al. The paediatric clinical experiences of general practice registrars. Aust Fam Physician 2012;41:529–33.
  7. Cooke G, Valenti L, Glasziou P, et al. Common general practice presentations and publication frequency. Aust Fam Physician 2013;42:65–68.
  8. World Health Organization. Classifications. International Statistical Classification of Diseases and Related Health Problems. ICD-10 Online. Current version, 2010. Geneva: WHO, 2015. Available at: http://apps.who.int/classifications/icd10/browse/2015/en [Accessed 5 May 2015].
  9. Confederation of Postgraduate Medical Education Councils. Australia Curriculum Framework for Junior Doctors. Melbourne: Australia Curriculum Framework for Junior Doctors, 2014. Available at http://curriculum.cpmec.org.au/ [Accessed 27 March 2015].
  10. Australian Institute of Health and Welfare. Australian hospital statistics 2012–13. Health services series no. 54 Cat. no. HSE 145. Canberra: AIHW, 2014. Available at www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547000 [Accessed 27 March 2015].
  11. Health Workforce Australia 2012. The effects of medical graduate expansion in Australia – Final Report, March 2012. Adelaide: HWA, 2012.
  12. Scallan S. Training for general practice in the foundation programme: lessons from the pre-registration house officer experience. Educ Prim Care 2005;16:256–64.
  13. Australian Medical Council. Intern training - Guidelines for terms. Canberra: AMC, 2013. Available at www.amc.org.au/images/Accreditation/Intern_training-Guidelines_for_terms_2013_12_18.pdf [Accessed 27 March 2015].
  14. Morefield K, Anthony, A, Bain, R, Jones, A. Core terms in emergency medicine for interns in South Australia: Training experiences in emergency departments and in general practice settings with emergency exposure. Adelaide: South Australian Medical Education and Training, 2014.
  15. Croft SJ, Kuhrt A, Mason S. Are today’s junior doctors confident in managing patients with minor injury? EMJ 2006;23:867–68.
  16. Health Workforce Australia 2012. Australia’s Health Workforce Series – Doctors in focus. Adelaide: HWA, 2012.
  17. Bindman AB, Forrest CB, Britt H, et al. Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys. BMJ 2007;334:1261.
  18. Stange KC, Jaen CR, Flocke SA, et al. The value of a family physician. J Fam Pract 1998;46:363–68.
  19. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377–89. 

Correspondence afp@racgp.org.au

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Type

Research

2015