The provision of clinical procedural services has been, and remains, an integral part of general practice. In Australia, as in many other countries, general practitioners’ (GPs’) provision of procedures is especially important in rural areas.1,2 As the future primary care workforce, it is imperative that general practice registrars learn and refine procedural skills.3 A number of institutions and organisations have sought to develop a list of core procedural skills for general practice registrars.4–7 In 2011, Sylvester et al8 developed (via a Delphi process) a list of 112 core procedures, plus a supplementary list containing 79 other procedures, to be used as a resource on which to base general practice procedures training curricula. The 112 core procedures were deemed those that a general practice registrar should have experience in performing during their general practice training. Although this core list has not been adopted by relevant organisations, such as The Royal Australian College of General Practitioners (RACGP), in their curricula, it provides a useful indication for procedural skills reasonable for registrars to be taught.
Although a number of such general practice procedure checklists exist, little is known about general practice trainees’ actual performance of clinical procedures, especially in Australian settings. A study from Germany found that general practice trainees expressed difficulty in independently performing a number of common general practice procedures.9 Other studies from US have shown incongruity between program director expectations and intern self-reported ability to perform common procedures in family medicine and surgery programs.10,11
The aims of this study were to investigate the type and frequency with which clinical procedures are performed by Australian general practice registrars; establish the level of concordance of registrars’ performance of procedures with a list of core clinical procedural skills developed for the Australian general practice training context;8 and establish associations of performing procedures with rurality of practice and general practice registrars’ in-consultation seeking supervisor advice or assistance.
Method
We performed a cross-sectional analysis of data from the longitudinal Registrar Clinical Encounters in Training (ReCEnT) study.12 ReCEnT is an ongoing, multicentre cohort study of general practice registrars’ in-consultation clinical and educational experiences. Participants were registrars who were enrolled (2010–2015) with five of Australia’s 17 general practice regional training providers (RTPs) across five of Australia’s six states, and (from 2016) with three of Australia’s nine regional training organisations (RTOs) in three states (in late 2015, there was a major restructure of Australian general practice training).
In ReCEnT, registrars undertake data collection once in each of three six-month training terms (or per 12-month term for part-time registrars) as an integral part of their educational program.13 In one RTP, some registrars undertaking a non-compulsory fourth general practice-based term also contributed data.
Informed consent is obtained for registrars’ de-identified data used for research purposes. Initial data collection includes information on the registrars’ demographic and characteristics of the practice where they work. Data are recorded by each registrar, each training term. Registrars also record detailed data of 60 consecutive clinical consultations per term via a paper-based encounter form. Data collection is performed approximately mid-way through the term. As data collection is intended to reflect ‘normal’ general practice activity, consultations in a specialised clinic (eg vaccination clinic) are excluded. Only office-based (ie not home visits, nursing home visits, hospital-based) consultations are recorded. The in-consultation data encompass four broad areas:
- patient demographics
- diagnoses or problems managed
- investigations or management (including referral and follow-up)
- educational training aspects (whether the registrar sought in-consultation advice or information from their clinical supervisor or from other sources, or generated learning goals).
The list of the procedures recorded in ReCEnT was adopted from the core list (n = 112), which was developed by Sylvester et al,8 plus the additional general practice procedures included in that project (n = 79). When defining ‘procedure’, we used the same criteria used by Sylvester et al8 to define a general practice clinical procedure (Box1).
Other independent variables recorded related to:
- Patient – age, gender, Aboriginal or Torres Strait Islander status, non-English speaking background, new to the practice or new to the registrar
- Registrar – age, gender, part-time or full-time workload, training term, Australian graduate or international medical graduate (IMG), previous training in the practice
- Practice – rurality, practice size, socioeconomic status (SES), billing, RTP
- Consultation – if the registrar sought in-consultation advice, assistance or information related to the procedure from their supervisor or other physicians in the practice, new problem, number of problems, duration of consultation.
The practices’ postcodes were used to define the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) classification (degree of rurality) and the Socio-Economic Index for Areas’s (SEIFA’s) index of disadvantage of the practice location.14
Box 1. Criteria used for defining a general practice clinical procedure8
Discrete activity performed on a patient
Requires knowledge and psychomotor or manual skill
Diagnostic or therapeutic
May or may not require the use of equipment
Invasive or noninvasive
Excludes manual skills which are part of routine clinical examination
Excludes purely interpretive skills
Excludes complex surgical procedures that require a general anaesthetic
|
Statistical methods
Descriptive analyses were used to describe the frequency of the individual procedures performed per 10,000 patient consultations.
Associations of performing procedures with independent variables were tested using chi-square analyses. Analyses were performed at the level of problem or diagnosis rather than consultation. We performed two primary analyses and tested the association of registrars performing a procedure for a problem with:
- Practice geographic location (rurality) – We classified the five categories of the ASGC-RA to three levels (‘Major cities’, ‘Inner regional’ and ‘Outer regional, remote, very remote’)
- Accessing advice or assistance from their supervisor.
Secondary analyses were undertaken to test the association of performing procedures with the remaining aforementioned independent variables.
For primary analyses, P values <0.05 were considered statistically significant. For the secondary analysis, multiple comparisons (n = 19) were adjusted for using a Bonferroni adjustment, with an adjusted P value of <0.003 determining statistical significance.
All analyses were conducted using Stata statistical software (version 13.1).
Ethics approval
The ReCEnT project has approval from the University of Newcastle’s Human Research Ethics Committee (reference: H-2009-0323).
Results
A total of 1299 registrars (response rate: 95.8%) contributed 3077 registrar-rounds of data collection and 182,782 consultations (283,616 problems or diagnoses) from 2010 to 2016. Table 1 shows registrar and practice demographics.
Overall, 19,411 procedures were performed by registrars during this period. Procedures were performed in 9.9% (95% confidence interval [CI]: 9.8, 10.1) of consultations for 6.8% (95% CI: 6.7, 6.9) of problems or diagnoses managed. Table 2 presents the number and rate per 10,000 consultations of the 30 most commonly performed procedures. Numbers and rates are presented by AGSC–RA derived level of rurality, and for all areas combined. The full list of procedures performed by registrars is available as Appendix 1 (available online only). The most commonly performed procedures were intramuscular injection, Papanicolaou (Pap) test and cryotherapy. Eighty-five per cent of the procedures from Sylvester’s list of core general practice vocational training procedures (n = 112) were performed by the registrars. The frequency of the majority of these, however, was very low (Appendix 1; available online only). For the list of all procedures (core list plus supplementary list; n = 191), one-third of procedures was not performed by the registrars. These could mostly be considered hospital-based procedures (eg obstetric procedures, emergency department procedures; Box 2). An anomaly was the insertion of intrauterine devices (IUDs), which is not included in the core procedural skills list, but performed in 21 registrar consultations.
Table 1. Characteristics of registrars and practices
Registrars and registrar-round characteristics
|
|
n (%) [95% confidence interval (CI)]
|
Registrar characteristics (n = 1294)
|
|
|
Gender
|
Female
Male
|
848 (65.5%) [62.9, 68.1]
446 (34.5%) [31.9, 37.1]
|
Qualified as a doctor in Australia
|
Yes
No
|
1070 (83.5%) [81.3, 85.4]
212 (16.5%) [14.6, 18.7]
|
Registrar-round characteristics (n = 3001)
|
|
|
Age (years)
|
Mean ± SD
|
32.6 ± 6.4
|
Registrar training term
|
Term 1
|
1198 (39.9%) [38.2, 41.7]
|
|
Term 2
|
1013 (33.8%) [32.1, 35.5]
|
|
Term 3
|
790 (26.3%) [24.8, 27.9]
|
Registrar worked at the practice previously
|
Yes
|
771 (26.1%) [24.5, 27.7]
|
Registrar works full-time
|
Yes
|
2272 (77.4%) [75.9, 78.9]
|
Practice characteristics (n = 3077)
|
|
|
Practice routinely bulk bills*
|
Yes
|
531 (17.8%) [16.5, 19.2]
|
Number of full-time equivalent GPs working at the practice
|
1–5
|
1003 (34.3%) [32.6, 36.0]
|
|
6+
|
1923 (65.7%) [64.0, 67.4]
|
Rurality of practice
|
Major City
|
1712 (57.1%) [55.3, 58.9]
|
|
Inner Regional
|
786 (26.2%) [24.7, 27.8]
|
|
Outer regional, remote, very remote
|
500 (16.8%) [15.4, 18.1]
|
Socioeconomic Index for Area: Relative Index of Disadvantage
|
Mean ± SD
|
5.5 ± 2.9
|
*’Bulk bills’ means no financial cost to the patient
|
Associations – Primary analyses
Overall, performing procedures was significantly associated with registrars working in an ‘Outer regional, remote, very remote’ location, compared with ‘Major city’ and ‘Inner regional’ locations (8%; 95% CI: 7.7, 8.2 versus 6.7%; 95% CI: 6.6, 6.9) versus 6.4% (95% CI: 6.2, 6.5; P <0.001). Relatively fewer Pap tests, however, were performed with increasing practice rurality (Table 2).
Performing procedures was significantly associated with registrars seeking help from their supervisor (9%; 95% CI: 8.6, 9.4 versus 6.7%; 95% CI: 6.6, 6.8; P <0.001).
Regarding the type of procedures for which registrars commonly sought supervisors’ help, most could be characterised as ‘complex’, ‘advanced’ or ‘invasive’, and requiring a higher level of skills. For example, injection and/or aspiration of shoulders (registrars sought their supervisor’s assistance or advice in 57.6% of such episodes), wedge excision for ingrown toenail (45.5%), and injection and/or aspiration of knee joint (45.5%). Procedures for which registrars infrequently sought help (<5% of episodes) included simpler procedures, such as intramuscular injection, Pap test, dry needling and removal of ear wax (data not shown in tabular form).
Table 2. List of the 30 most common procedures performed by registrars
Procedure
|
All areas
|
Major cities
|
Inner regional
|
Outer regional, remote, very remote
|
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
Procedure
|
5778
|
316.1
|
3424
|
330.0
|
1262
|
258.9
|
1082
|
359.0
|
Pap smear
|
4160
|
227.6
|
2526
|
243.5
|
1046
|
214.6
|
585
|
194.1
|
Cryotherapy
|
1968
|
107.7
|
1107
|
106.7
|
500
|
102.6
|
358
|
118.8
|
Application of wound dressings
|
880
|
48.1
|
522
|
50.3
|
239
|
49.0
|
119
|
39.5
|
Syringe external auditory canal
|
712
|
39.0
|
394
|
38.0
|
172
|
35.3
|
145
|
48.1
|
Excision of superficial skin lesions
|
622
|
34.0
|
254
|
24.5
|
202
|
41.4
|
166
|
55.1
|
Set up and record 12 lead electrocardiography
|
550
|
30.1
|
195
|
18.8
|
180
|
36.9
|
173
|
57.4
|
Taking of high vaginal swab
|
443
|
24.2
|
257
|
24.8
|
107
|
21.9
|
79
|
26.2
|
Venepuncture
|
398
|
21.8
|
117
|
11.3
|
40
|
8.2
|
234
|
77.6
|
Punch biopsy of skin lesion
|
373
|
20.4
|
157
|
15.1
|
115
|
23.6
|
100
|
33.2
|
Incision and drainage of abscess
|
277
|
15.2
|
150
|
14.5
|
61
|
12.5
|
66
|
21.9
|
Subcutaneous injection
|
238
|
13.0
|
149
|
14.4
|
49
|
10.1
|
40
|
13.3
|
Insertion of Implanon rod
|
215
|
11.8
|
106
|
10.2
|
56
|
11.5
|
53
|
17.6
|
Suture of superficial skin laceration
|
207
|
11.3
|
120
|
11.6
|
53
|
10.9
|
34
|
11.3
|
Spirometry
|
165
|
9.0
|
81
|
7.8
|
31
|
6.4
|
53
|
17.6
|
Removal of Implanon rod
|
128
|
7.0
|
62
|
6.0
|
41
|
8.4
|
25
|
8.3
|
Removal of subcutaneous foreign body
|
112
|
6.1
|
58
|
5.6
|
29
|
5.9
|
25
|
8.3
|
Removal of ear wax
|
108
|
5.9
|
65
|
6.3
|
23
|
4.7
|
20
|
6.6
|
Shave biopsy of skin lesion
|
106
|
5.8
|
47
|
4.5
|
36
|
7.4
|
23
|
7.6
|
Wound debridement
|
100
|
5.5
|
47
|
4.5
|
35
|
7.2
|
18
|
6.0
|
Soft tissue injury strapping
|
98
|
5.4
|
66
|
6.4
|
17
|
3.5
|
15
|
5.0
|
Throat swab
|
93
|
5.1
|
46
|
4.4
|
25
|
5.1
|
22
|
7.3
|
Wound swab
|
92
|
5.0
|
47
|
4.5
|
25
|
5.1
|
20
|
6.6
|
Application of forearm back-slab
|
70
|
3.8
|
40
|
3.9
|
20
|
4.1
|
10
|
3.3
|
Perform peak flow measurement
|
69
|
3.8
|
50
|
4.8
|
16
|
3.3
|
3
|
1.0
|
Application of forearm cast
|
59
|
3.2
|
33
|
3.2
|
14
|
2.9
|
12
|
4.0
|
Removal of corneal foreign body
|
58
|
3.2
|
25
|
2.4
|
16
|
3.3
|
17
|
5.6
|
Epley manoeuvre for benign positional vertigo
|
51
|
2.8
|
37
|
3.6
|
9
|
1.8
|
5
|
1.7
|
Excision of sebaceous cyst
|
49
|
2.7
|
28
|
2.7
|
12
|
2.5
|
9
|
3.0
|
Intravenous access
|
48
|
2.6
|
15
|
1.4
|
12
|
2.5
|
21
|
7.0
|
Associations – Secondary analyses
Appendix 2 (available online only) shows the associations of registrars’ performing procedures with independent variables.
Discussion
In this study, we established the type and frequency of procedures performed by Australian general practice registrars and compared it with a list of procedures developed by Sylvester et al8 that is deemed to be core to general practice training. To our knowledge, this is the first study in Australia investigating the scope of procedures performed by general practice registrars.
We found that the frequency with which the majority of core procedures were performed was low, with only three procedures (ie intramuscular injection, Pap test and cryotherapy) with a rate above 100 per 10,000 encounters. Data from one RTO suggest registrars conduct approximately 60 patient consultations per week over the training period (including data for part-time and full-time registrars; personal communication from Amanda Tapley). Our findings, together with this consideration, raise the possibility of many registrars not having adequate procedural exposure to become competent in many basic procedural skills on entering independent practice. In addition, there was a lack of technically more advanced procedures (eg fracture-related procedures) performed by registrars.
These findings are also particularly concerning as some registrars will be practising in rural centres where a lack of competency in procedural skills could significantly limit their practice and, in the case of some skills, may have implications for patient safety. Previous research has found that the number of rural GPs offering procedural services, and the complexity of these services, has been in gradual decline over the past three decades.15 A possible lack of early career GPs’ competency in procedural skills may contribute to this decline.
Australian general practice data16 report 11.4 procedures per 100 problems managed by Australian GPs in 2015–16. This is higher than our general practice registrar data. Although the difference might represent patients self-selecting to see own GPs rather than a trainee to have a procedure, it may also be influenced by different definitions of procedure between studies.
A number of associations of performing procedures found in this study are relevant to practice. We found that registrar performed more procedures in rural than in urban centres. However, Pap tests were performed by registrars at a lower rate in rural centres. A lower proportion of female registrars in ‘Outer regional, remote, very remote’ (personal communication from Amanda Tapley) may have influenced this finding.
We found that registrars often sought advice or assistance when performing what the authors of this study would consider more complex or advanced procedures. This is unsurprising as the very complexity of these procedures would mandate supervision during early experiences of learning and mastering any such procedure. However, the high proportions of episodes involving supervisor advice or assistance for the more complex or advanced procedures may also reflect the overall low frequency with which they were performed (with not enough individual procedures performed by individual registrars to achieve a level of proficiency necessary for independent, unsupervised performance of the procedure).
Strengths and limitations
Strengths of this study include the large number of consultations recorded and the use of a rigorously derived list of procedures relevant to general practice.8 The high response rate13 and inclusion of data from five Australian states across all rurality classifications, from major city to very remote areas, suggest excellent generalisability to the wider Australian general practice vocational training program.
A limitation of this study is that we do not know the supervisors’ skill levels or the available opportunities for registrars to perform particular procedures. Another limitation is that our data are limited to office-based consultations. We did not capture procedures done in hospitals by the relatively small proportion of registrars in rural and remote practices who have hospital-admitting privileges. This may also explain the lack of hospital-based procedures from the core and supplementary lists.8 Implications drawn from our data also do not take into account procedures experienced in hospital practice prior to general practice terms. In addition, our data cannot measure how well or safely these procedures were done by the registrars. Again, the small number of more advanced or complex procedures performed and the high proportions of these done with supervisor support suggest that there may be very limited competency acquired in these procedures.
Implications for policy and practice
Our findings suggest suboptimal registrar exposure to relevant clinical procedures. Responses may include greater use of laboratory-based training and encouraging supervisors to more often involve their registrars when they (the supervisor) preform procedures. Alternatively, our conception of the appropriate scope of procedural skills of graduates of general practice vocational training may need to be narrowed.
Box 2. Procedures not performed by registrars (n = 67)
Allergy skin prick testing
Application of full leg cast
Application of walking heel to a plaster
Artificial rupture of membranes
Aspiration of hydrocoele
Axillary nerve block
Bier’s block
Biphasic positive airway pressure (BIPAP)
Bone marrow aspiration
Cardiopulmonary (CPR; child)
Circumcision
Cricothyroidotomy
Cutdown venous access
Defibrillation
Diagnostic peritoneal lavage
Emergency use of mechanical ventilators
Endometrial aspiration biopsy
Endotracheal intubation (adult)
Endotracheal intubation (child)
Episiotomy and repair
Femoral nerve block
Forceps extraction
Fracture haematoma block
Gastric lavage
Haemorrhoid banding
Haemorrhoid injection
Injection of carpal tunnel
Injection of Trigger finger
Insertion of chest tube
Insertion of laryngeal mask
Insertion of nasopharyngeal airway
Insertion of oral airway
Intercostal nerve block
Interosseous needle insertion
Jet insufflation
Lumbar puncture
Measurement of intra-occular pressure
Mouth to mask ventilation
Mouth to mouth ventilation
Needle cricothyroidotomy (child)
Neonatal intubation
Normal vaginal delivery
Orogastric tube insertion
Paracentesis
Pericardiocentesis
Pudendal block
Rapid sequence induction
Reduce ankle fractures
Reduce wrist fractures
Reduction of dislocated hip
Reduction of dislocated patella
Reduction of dislocated shoulder
Reduction of paraphimosis
Reduction tension pneumothorax
Repair tendon laceration
Scalp clip attachment
Sigmoidoscopy
Suprapubic aspiration (child)
Suprapubic catheterisation
Synchronised direct current (DC) cardioversion (adult)
Synchronised direct current (DC) (child)
Thoracocentesis
Tibial nerve block
Umbilical catheter
Urethral catheterisation (child)
Urethral catheterisation of a female
Vacuum extraction
|
Authors
Fariba Aghajafari MD, MSc, PhD, CCFP, FCFP, Assistant Professor, Department of Family Medicine, Cumming School of Medicine, University of Calgary, Sunridge Family Medicine Teaching Centre, Calgary, AG, Canada. fariba.aghajafari@ucalgary.ca
Amanda Tapley BBiomedSci (Hons), MMedStats, Senior Research Officer, GP Synergy Research and Evaluation Unit, NSW; and Conjoint Fellow, School of Medicine and Public Health, University of Newcastle, NSW
Steve Sylvester MBChB, MRCP, MMedEd, FRACGP, FARGP, GP Supervisor, Scone Medical Practice, NSW
Andrew R Davey BSc, BE (Hons), DCH, BMed, MClinEpid, FRACGP, Senior Researcher, GP Synergy Research and Evaluation Unit, NSW
Simon Morgan MBBS, MPH, FRACGP, General Practitioner, Elermore Vale General Practice, NSW
Kim M Henderson BNurs, GradDip HlthSocSci, ReCEnT Project Manager, GP Synergy Research and Evaluation Unit, NSW; and Conjoint Fellow, School of Medicine and Public Health, University of Newcastle, NSW
Mieke L van Driel MD, MSc, PhD, FRACGP, Professor of General Practice, Head of Discipline of General Practice and Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Qld
Neil A Spike MBBS, FRACGP, Director of Training, EVGP Training, Vic; and Professorial Fellow, Department of General Practice, University of Melbourne, Vic
Rohan H Kerr MBBS, FRACGP, FARGP, GradCert Uni Teaching and Learning, Director of Education, General Practice Training Tasmania, Tas
Nigel F Catzikiris BE (Envl) (Hons), BExSci, BHealth, Grad Dip Teaching and Learning, Research Assistant, GP Synergy Research and Evaluation Unit, NSW; and Conjoint Fellow, School of Medicine and Public Health, University of Newcastle, NSW
Katie J Mulquiney BND (Hons), Research Assistant, GP Synergy Research and Evaluation Unit, NSW; and Conjoint Fellow, School of Medicine and Public Health, University of Newcastle, NSW
Parker J Magin PhD, FRACGP, Director, GP Synergy Research and Evaluation Unit, NSW; Conjoint Professor School of Medicine and Public Health, University of Newcastle, NSW
Competing interests and funding: The project was funded in 2010–15 by General Practice Training Valley to Coast, the Victorian Metropolitan Alliance, General Practice Training Tasmania, Tropical Medicine Training and Adelaide to Outback GP Training Program. These organisations were funded by the Australian Government. In 2016, the project was funded by the Australian Department of Health (commissioned research grant) and supported by GP Synergy Regional Training Organisation.
Provenance and peer review: Not commissioned, externally peer reviewed.
Appendix 1. List of the procedures done by registrars (n = 124)
Procedure
|
All areas
|
Major cities
|
Inner regional
|
Outer regional, remote, very remote
|
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
Intramuscular injection
|
5778
|
316.1
|
3424
|
330.0
|
1262
|
258.9
|
1082
|
359.0
|
Pap smear
|
4160
|
227.6
|
2526
|
243.5
|
1046
|
214.6
|
585
|
194.1
|
Cryotherapy
|
1968
|
107.7
|
1107
|
106.7
|
500
|
102.6
|
358
|
118.8
|
Application of wound dressings
|
880
|
48.1
|
522
|
50.3
|
239
|
49.0
|
119
|
39.5
|
Syringe external auditory canal
|
712
|
39.0
|
394
|
38.0
|
172
|
35.3
|
145
|
48.1
|
Excision of superficial skin lesions
|
622
|
34.0
|
254
|
24.5
|
202
|
41.4
|
166
|
55.1
|
Set up and record 12 lead electrocardiography
|
550
|
30.1
|
195
|
18.8
|
180
|
36.9
|
173
|
57.4
|
Taking of high vaginal swab
|
443
|
24.2
|
257
|
24.8
|
107
|
21.9
|
79
|
26.2
|
Venepuncture
|
398
|
21.8
|
117
|
11.3
|
40
|
8.2
|
234
|
77.6
|
Punch biopsy of skin lesion
|
373
|
20.4
|
157
|
15.1
|
115
|
23.6
|
100
|
33.2
|
Incision and drainage of abscess
|
277
|
15.2
|
150
|
14.5
|
61
|
12.5
|
66
|
21.9
|
Subcutaneous injection
|
238
|
13.0
|
149
|
14.4
|
49
|
10.1
|
40
|
13.3
|
Insertion of Implanon rod
|
215
|
11.8
|
106
|
10.2
|
56
|
11.5
|
53
|
17.6
|
Suture of superficial skin laceration
|
207
|
11.3
|
120
|
11.6
|
53
|
10.9
|
34
|
11.3
|
Spirometry
|
165
|
9.0
|
81
|
7.8
|
31
|
6.4
|
53
|
17.6
|
Removal of Implanon rod
|
128
|
7.0
|
62
|
6.0
|
41
|
8.4
|
25
|
8.3
|
Removal of subcutaneous foreign body
|
112
|
6.1
|
58
|
5.6
|
29
|
5.9
|
25
|
8.3
|
Removal of ear wax
|
108
|
5.9
|
65
|
6.3
|
23
|
4.7
|
20
|
6.6
|
Shave biopsy of skin lesion
|
106
|
5.8
|
47
|
4.5
|
36
|
7.4
|
23
|
7.6
|
Wound debridement
|
100
|
5.5
|
47
|
4.5
|
35
|
7.2
|
18
|
6.0
|
Soft tissue injury strapping
|
98
|
5.4
|
66
|
6.4
|
17
|
3.5
|
15
|
5.0
|
Throat swab
|
93
|
5.1
|
46
|
4.4
|
25
|
5.1
|
22
|
7.3
|
Wound swab
|
92
|
5.0
|
47
|
4.5
|
25
|
5.1
|
20
|
6.6
|
Application of forearm back-slab
|
70
|
3.8
|
40
|
3.9
|
20
|
4.1
|
10
|
3.3
|
Perform peak flow measurement
|
69
|
3.8
|
50
|
4.8
|
16
|
3.3
|
3
|
1.0
|
Application of forearm cast
|
59
|
3.2
|
33
|
3.2
|
14
|
2.9
|
12
|
4.0
|
Removal of corneal foreign body
|
58
|
3.2
|
25
|
2.4
|
16
|
3.3
|
17
|
5.6
|
Epley manoeuvre for benign positional vertigo
|
51
|
2.8
|
37
|
3.6
|
9
|
1.8
|
5
|
1.7
|
Excision of sebaceous cyst
|
49
|
2.7
|
28
|
2.7
|
12
|
2.5
|
9
|
3.0
|
Intravenous access
|
48
|
2.6
|
15
|
1.4
|
12
|
2.5
|
21
|
7.0
|
Gluing of superficial lacerations
|
47
|
2.6
|
35
|
3.4
|
8
|
1.6
|
4
|
1.3
|
Appendix 1. List of the procedures done by registrars (n = 124) cont’d
Procedure
|
All areas
|
Major cities
|
Inner regional
|
Outer regional, remote, very remote
|
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
Removal of plaster or fibre-glass cast
|
45
|
2.5
|
21
|
2.0
|
14
|
2.9
|
10
|
3.3
|
Wedge excision for ingrown toenail
|
44
|
2.4
|
17
|
1.6
|
10
|
2.1
|
17
|
5.6
|
Intradermal injection
|
42
|
2.3
|
20
|
1.9
|
10
|
2.1
|
12
|
4.0
|
Fungal scraping
|
40
|
2.2
|
20
|
1.9
|
9
|
1.8
|
11
|
3.6
|
Use slit lamp
|
40
|
2.2
|
13
|
1.3
|
5
|
1.0
|
22
|
7.3
|
Application of burn dressings
|
38
|
2.1
|
30
|
2.9
|
6
|
1.2
|
2
|
0.7
|
Removal of sub-tarsal foreign body
|
37
|
2.0
|
22
|
2.1
|
8
|
1.6
|
7
|
2.3
|
Application of aluminium splint to finger
|
36
|
2.0
|
19
|
1.8
|
11
|
2.3
|
6
|
2.0
|
Dry needling
|
34
|
1.9
|
34
|
3.3
|
0
|
0.0
|
0
|
0.0
|
Injection and/or aspiration of knee joint
|
33
|
1.8
|
15
|
1.4
|
11
|
2.3
|
7
|
2.3
|
Injection and/or aspiration of shoulder
|
33
|
1.8
|
16
|
1.5
|
10
|
2.1
|
7
|
2.3
|
Removal of foreign body from external audititory canal
|
33
|
1.8
|
14
|
1.3
|
13
|
2.7
|
6
|
2.0
|
Pare skin callus
|
32
|
1.8
|
20
|
1.9
|
5
|
1.0
|
7
|
2.3
|
Removal of intrauterine device
|
30
|
1.6
|
17
|
1.6
|
6
|
1.2
|
7
|
2.3
|
Ear toilet – Dry mopping
|
27
|
1.5
|
15
|
1.4
|
4
|
0.8
|
8
|
2.7
|
Post-nasal swab
|
27
|
1.5
|
15
|
1.4
|
6
|
1.2
|
6
|
2.0
|
Cautery for nasal bleeding
|
26
|
1.4
|
17
|
1.6
|
6
|
1.2
|
3
|
1.0
|
Audiogram
|
24
|
1.3
|
9
|
0.9
|
0
|
0.0
|
13
|
4.3
|
Curettage of skin lesion
|
24
|
1.3
|
19
|
1.8
|
3
|
0.6
|
2
|
0.7
|
Insertion of preloaded subcutanous hormone implants
|
24
|
1.3
|
13
|
1.3
|
10
|
2.1
|
1
|
0.3
|
Irrigation of eye
|
24
|
1.3
|
17
|
1.6
|
5
|
1.0
|
2
|
0.7
|
Application of below knee back-slab
|
21
|
1.1
|
9
|
0.9
|
9
|
1.8
|
3
|
1.0
|
Insertion of intrauterine device
|
21
|
1.1
|
8
|
0.8
|
8
|
1.6
|
5
|
1.7
|
Nebulization therapy
|
21
|
1.1
|
14
|
1.3
|
5
|
1.0
|
2
|
0.7
|
Application of sling – Upper extremity
|
20
|
1.1
|
10
|
1.0
|
3
|
0.6
|
7
|
2.3
|
Suture of deep skin lacerations
|
19
|
1.0
|
6
|
0.6
|
8
|
1.6
|
5
|
1.7
|
Insertion of wick into external ear canal
|
16
|
0.9
|
10
|
1.0
|
4
|
0.8
|
2
|
0.7
|
Application of below-knee cast
|
14
|
0.8
|
8
|
0.8
|
3
|
0.6
|
3
|
1.0
|
Electrocautery of skin lesions
|
14
|
0.8
|
5
|
0.5
|
7
|
1.4
|
2
|
0.7
|
Application of scaphoid cast
|
13
|
0.7
|
6
|
0.6
|
5
|
1.0
|
2
|
0.7
|
Appendix 1. List of the procedures done by registrars (n = 124) cont’d
Procedure
|
All areas
|
Major cities
|
Inner regional
|
Outer regional, remote, very remote
|
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
Digital nerve block
|
13
|
0.7
|
4
|
0.4
|
4
|
0.8
|
5
|
1.7
|
Drainage acute paronychia
|
13
|
0.7
|
8
|
0.8
|
4
|
0.8
|
1
|
0.3
|
Drainage of subungual hematoma
|
13
|
0.7
|
7
|
0.7
|
4
|
0.8
|
2
|
0.7
|
Injection and/or aspiration of olecranon bursa
|
12
|
0.7
|
5
|
0.5
|
7
|
1.4
|
0
|
0.0
|
Taking of urethral swab
|
12
|
0.7
|
9
|
0.9
|
2
|
0.4
|
1
|
0.3
|
Avulsion of a toenail
|
11
|
0.6
|
5
|
0.5
|
3
|
0.6
|
3
|
1.0
|
Central vein cannulation
|
11
|
0.6
|
5
|
0.5
|
1
|
0.2
|
5
|
1.7
|
Partial toenail removal
|
11
|
0.6
|
2
|
0.2
|
6
|
1.2
|
3
|
1.0
|
Drainage of perianal hematoma
|
9
|
0.5
|
2
|
0.2
|
4
|
0.8
|
3
|
1.0
|
Fine needle aspiration
|
9
|
0.5
|
8
|
0.8
|
1
|
0.2
|
0
|
0.0
|
Ear toilet – Micro-suction
|
8
|
0.4
|
3
|
0.3
|
0
|
0.0
|
5
|
1.7
|
Infiltration of local anaesthetic
|
9
|
0.4
|
3
|
0.3
|
2
|
0.4
|
3
|
1.0
|
Injection of plantar fasciitis
|
8
|
0.4
|
3
|
0.3
|
3
|
0.6
|
2
|
0.7
|
Injection of trochanteric bursa
|
8
|
0.4
|
4
|
0.4
|
1
|
0.2
|
3
|
1.0
|
Insertion of hormone implant by trochar/ cannula
|
8
|
0.4
|
5
|
0.5
|
1
|
0.2
|
2
|
0.7
|
Proctoscopy
|
8
|
0.4
|
5
|
0.5
|
1
|
0.2
|
2
|
0.7
|
Urethral catheterisation of a male
|
8
|
0.4
|
1
|
0.1
|
2
|
0.4
|
5
|
1.7
|
Spinal mobilisation
|
7
|
0.4
|
7
|
0.7
|
0
|
0.0
|
0
|
0.0
|
Administer oxygen via face mask
|
6
|
0.3
|
4
|
0.4
|
2
|
0.4
|
0
|
0.0
|
Application of full arm cast
|
6
|
0.3
|
4
|
0.4
|
2
|
0.4
|
0
|
0.0
|
Excision of lipoma
|
6
|
0.3
|
4
|
0.4
|
1
|
0.2
|
1
|
0.3
|
Injection and/or aspiration of elbow
|
6
|
0.3
|
1
|
0.1
|
2
|
0.4
|
3
|
1.0
|
Injection and/or aspiration of small joints
|
6
|
0.3
|
0
|
0.0
|
4
|
0.8
|
2
|
0.7
|
Injection of sub acromial space
|
6
|
0.3
|
3
|
0.3
|
2
|
0.4
|
1
|
0.3
|
Anterior nasal packing
|
5
|
0.3
|
3
|
0.3
|
1
|
0.2
|
1
|
0.3
|
Evacuation of haematoma
|
5
|
0.3
|
4
|
0.4
|
1
|
0.2
|
0
|
0.0
|
Vasectomy
|
5
|
0.3
|
1
|
0.1
|
2
|
0.4
|
2
|
0.7
|
Application of eye patch
|
3
|
0.2
|
3
|
0.3
|
0
|
0.0
|
0
|
0.0
|
Arterial blood sampling
|
3
|
0.2
|
1
|
0.1
|
0
|
0.0
|
2
|
0.7
|
Flap repairs
|
3
|
0.2
|
0
|
0.0
|
1
|
0.2
|
2
|
0.7
|
Injection and/or aspiration of pre-patellar bursa
|
3
|
0.2
|
2
|
0.2
|
1
|
0.2
|
0
|
0.0
|
Skin graft repair
|
3
|
0.2
|
0
|
0.0
|
0
|
0.0
|
3
|
1.0
|
Application of cervical hard collar
|
2
|
0.1
|
1
|
0.1
|
1
|
0.2
|
0
|
0.0
|
Appendix 1. List of the procedures done by registrars (n = 124) cont’d
Procedure
|
All areas
|
Major cities
|
Inner regional
|
Outer regional, remote, very remote
|
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
N
|
per 10,000 encounter
|
Aspirate breast cyst
|
2
|
0.1
|
1
|
0.1
|
0
|
0.0
|
1
|
0.3
|
Continuous positive airway pressure (CPAP)
|
2
|
0.1
|
0
|
0.0
|
0
|
0.0
|
2
|
0.7
|
Indirect laryngoscopy
|
2
|
0.1
|
0
|
0.0
|
0
|
0.0
|
2
|
0.7
|
Injection and/or aspiration of ankle
|
2
|
0.1
|
1
|
0.1
|
0
|
0.0
|
1
|
0.3
|
Injection of tendon sheath (wrist)
|
2
|
0.1
|
1
|
0.1
|
1
|
0.2
|
0
|
0.0
|
Injection of tennis elbow
|
2
|
0.1
|
2
|
0.2
|
0
|
0.0
|
0
|
0.0
|
Posterior nasal packing
|
2
|
0.1
|
0
|
0.0
|
2
|
0.4
|
0
|
0.0
|
Reduction of dislocated radial head
|
2
|
0.1
|
1
|
0.1
|
1
|
0.2
|
0
|
0.0
|
Removal of corneal rust ring
|
2
|
0.1
|
0
|
0.0
|
0
|
0.0
|
2
|
0.7
|
Removal of fish hook
|
2
|
0.1
|
0
|
0.0
|
0
|
0.0
|
2
|
0.7
|
Bartholin cyst marsupialization
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Cardiopulmonary resuscitation (CPR; adult)
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Chalazion curettage
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Diaphragm fitting and insertion
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Drainage of perianal abscess
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Facial nerve blocks
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Faecal dis-impaction
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Injection of bicipital tendonitis
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Injection trigger points
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
1
|
0.3
|
Nasogastric tube insertion
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Physical therapy for acute torticollis
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Quinsy incision and drainage
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Re-insertion of avulsed tooth
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Reduce metacarpal fractures
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Reduction of dislocated temporomandibular joint (TMJ)
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Reduction of dislocated finger
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Removal of foreign body from nose
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Removal of ring (from swollen finger)
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Spinal manipulation
|
1
|
0.1
|
0
|
0.0
|
1
|
0.2
|
0
|
0.0
|
Tympanogram
|
1
|
0.1
|
1
|
0.1
|
0
|
0.0
|
0
|
0.0
|
Appendix 2. Characteristics associated with general practice registrars’ performance of procedures
Variable
|
Class
|
No (n = 257,931) n (%)
|
Yes (n = 18,934) n (%)
|
P value
|
Patient age group
|
0–14
|
35,946 (94.2)
|
2229 (5.8)
|
<0.001
|
|
15–34
|
66,459 (93.3)
|
4778 (6.7)
|
|
|
35–64
|
102,237 (93.2)
|
7428 (6.8)
|
|
|
≥65
|
49,407 (92.2)
|
4187 (7.8)
|
|
Patient gender
|
Male
|
94,019 (93.7)
|
6321 (6.3)
|
<0.001
|
|
Female
|
15,7079 (92.8)
|
12,124 (7.2)
|
|
Aboriginal and/or Torres Strait Islander status
|
No
|
239,229 (93.1)
|
17,607 (6.9)
|
<0.001
|
|
Yes
|
1868 (95.4)
|
186 (4.69)
|
|
Non-English speaking background
|
No
|
228,186 (93.2)
|
16,686 (6.8)
|
0.629
|
|
Yes
|
16,899 (93.1)
|
1254 (6.9)
|
|
Patient or practice status
|
Existing patient
|
110,266 (93.7)
|
7437 (6.3)
|
<0.001
|
|
New to registrar
|
124,412 (92.7)
|
9762 (7.3)
|
|
|
New to practice
|
17,079 (93.1)
|
1272 (6.9)
|
|
Registrar gender
|
Male
|
86,815 (94.2)
|
5365 (5.8)
|
<0.001
|
|
Female
|
171,116 (92.7)
|
13,569 (7.4)
|
|
Registrar full-time or part-time*
|
Part-time
|
58,347 (93.1)
|
4330 (6.9)
|
0.542
|
|
Full-time
|
193,949 (93.2)
|
14,236 (6.8)
|
|
Registrar training term
|
Term 1
|
104,220 (92.4)
|
8595 (7.6)
|
<0.001
|
|
Term 2
|
86,220 (94.0)
|
5554 (6.1)
|
|
|
Term 3
|
67,491 (93.4)
|
4785 (6.6)
|
|
Registrar worked at practice previously
|
No
|
187,197 (93.0)
|
14201 (7.1)
|
<0.001
|
|
Yes
|
67,055 (93.7)
|
4499 (6.3)
|
|
Registrar qualified as doctor in Australia
|
No
|
48,735 (93.8)
|
3203 (6.2)
|
<0.001
|
|
Yes
|
207,141 (93.0)
|
15,619 (7.0)
|
|
Practice size
|
Small (1–5 GPs)
|
87,011 (92.5)
|
7091 (7.5)
|
<0.001
|
|
Large (≥6 GPs)
|
164,490 (93.5)
|
11,410 (6.5)
|
|
Practice routinely bulk bills
|
No
|
211,094 (93.1)
|
15,699 (6.9)
|
<0.001
|
|
Yes
|
45,677 (93.5)
|
3160 (6.5)
|
|
Regional Training Provider (RTP)
|
RTP 1
|
71,825 (94.2)
|
4442 (5.8)
|
<0.001
|
|
RTP 2
|
33,611 (92.9)
|
2584 (7.1)
|
|
|
RTP 3
|
33,906 (92.1)
|
2920 (7.9)
|
|
|
RTP 4
|
108,861 (92.9)
|
8304 (7.1)
|
|
|
RTP 5
|
9728 (93.4)
|
684 (6.6)
|
|
New problem seen
|
No
|
107,583 (95.7)
|
4879 (4.3)
|
<0.001
|
|
Yes
|
12,8507 (91.4)
|
12033 (8.6)
|
|
Registrar age
|
Median (Q1, Q3)
|
30.6 (28.1, 35.1)
|
30.5 (28.0, 34.7)
|
0.0351
|
|
Mean (standard deviation [SD])
|
32.6 (6.3)
|
32.5 (6.3)
|
|
Socioeconomic Index for Area: Relative Index of Disadvantage
|
Median (Q1, Q3)
|
5 (3, 8)
|
5 (3, 8)
|
0.0935
|
|
Mean (SD)
|
5.4 (2.9)
|
5.5 (3.0)
|
|
Number of problems
|
Median (Q1, Q3)
|
2 (1, 3)
|
2 (1, 2)
|
<0.0001
|
|
Mean (SD)
|
2.0 (1.0)
|
1.8 (0.9)
|
|
Duration of consultation
|
Median (Q1, Q3)
|
17 (12, 24)
|
18 (12, 26)
|
<0.0001
|
|
Mean (SD)
|
18.9 (9.8)
|
20.3 (11.1)
|
|
Duration of consultation (at level of consultation)
|
Median (Q1, Q3)
|
15 (11, 21)
|
18 (12, 25)
|
<0.0001
|
|
Mean (SD)
|
17.1 (9.0)
|
20.1 (10.9)
|
|
*Full-time constitutes eight or more sessions per week
|
|
|
|