Menopause

June 2017

Research

Procedural skills of Australian general practice registrars: A cross-sectional analysis

Volume 46, No.6, June 2017 Pages 429-434

Fariba Aghajafari

Amanda Tapley

Steve Sylvester

Andrew R Davey

Simon Morgan

Kim M Henderson

Mieke van Driel

Neil A Spike

Rohan H Kerr

Nigel F Catzikiris

Katie J Mulquiney

Parker J Magin

Background

Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training.

Methods

A cross-sectional analysis of a cohort study of registrars’ consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed.

Results

In 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed.

Discussion

Registrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.

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.

References

  1. Robinson M, Slaney GM, Jones GI, et al. GP proceduralists: ‘The hidden heart’ of rural and regional health in Australia. Rural Remote Health 2010;10(3):1402.
  2. Australian College of Rural and Remote medicine. Barriers to the maintenance of procedural skills in rural and remote medicine. Brisbane: ACRRM, 2002.
  3. The Royal Australian College of General Practitioners. The RACGP’s Competency profile of the Australian general practitioner at the point of Fellowship – CS2.2.5 Appropriate procedures are undertaken after receiving informed consent. Melbourne: RACGP, 2015.
  4. The Royal Australian College of General Practitioners. Making sense of GP learning – Companion to the RACGP training program curriculum. Melbourne: RACGP, 2005. Available at www.racgp.org. au/content/navigationmenu/educationandtrain- ing/curriculum/20050603racgpcompaniontraining program.pdf [Accessed 12 August 2010].
  5. Australian College of Rural and Remote Medicine. Core competencies procedural logbook. Brisbane: ACRRM, 2008.
  6. Wetmore SJ, Rivet C, Tepper J, Tatemichi S, Donoff M, Rainsberry P. Defining core procedure skills for Canadian family medicine training. Can Fam Physician 2005;51:1364–65.
  7. Nothnagle M, Sicilia J, Forman S, et al. Required procedural training in family medicine residency: A consensus statement. Fam Med 2008;40:248–52.
  8. Sylvester S, Magin P, Sweeney K, Morgan S, Henderson K. Procedural skills in general practice vocational training – What should be taught? Aust Fam Physician 2011;40(1–2):50–54.
  9. Jakel K, Flum E, Szecenyi J, Steinhäuser J. Which common general practice procedures can postgraduate registrars proficiently perform at the end of their medical studies? – A cross-sectional survey. Z Evid Fortbild Qual Gesundhwes 2016;115–116:85–92.
  10. Dickson GM, Chesser AK, Woods NK, Krug NR, Kellerman RD. Family Medicine residency program director expectations of procedural skills of medical school graduates. Fam Med 2013;45(6):392–99.
  11. Barr J, Graffeo CS. Procedural experience and confidence among graduating medical students. J Surg Edu 2016;73(3):466–73.
  12. Morgan S, Magin PJ, Henderson KM, et al. Study protocol: The Registrar Clinical Encounters in Training (ReCEnT) study. BMC Fam Pract 2012;13:50.
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  14. Australian Bureau of Statistics. Australian Standard Geographical Classification (ASGC), July 2011. Canberra: ABS, 2011. Available at www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/1216.0July%202011?OpenDocument [Accessed 11 April 2017].
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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

 

 

 

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

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