General practitioner anaesthesia survey 2006.
A survey was posted to all general practitioner anaesthetists in Australia who are currently involved in the Joint Consultative Committee on Anaesthesia (JCCA) accreditation process known as the Maintenance of Professional Standards program (MOPS). The survey was intended to gain information regarding accreditation, continuing medical education, caseloads, on call, work practices, attitudes and future work plans. The response rate was 70% (168/240). The majority of respondents worked in a rural location (73%) where there were no specialist anaesthetists (74%). Of the respondents, 89 were category A accredited, but only 15% had this based on completion of the Advanced Rural Skills Curriculum Statement in Anaesthesia (ARSCSA) and examination. The mean number of sessions in anaesthesia worked per week was 2.8 (SD 2.2). Of the respondents, 69% administered more than 150 anaesthetics per year. 28% were on call more than 10 times per month. General surgery, gastrointestinal endoscopy, obstetrics, gynaecology and orthopaedics were the most common specialties for which anaesthesia was provided. Eight percent of respondents stated that sedation comprised 81-100% of their caseload: 92% used propofol as part of their usual intravenous sedation technique: 90% provided anaesthesia for paediatric patients with a mean minimum age of 4.1 years (SD 3.4): 64% provided epidural anaesthesia/analgesia. The majority stated that specialist anaesthetists and hospital administrations were helpful and supportive. Eighty-two percent planned to continue or increase their current anaesthetic workload over the next five years. The JCCA MOPS program appears to provide a satisfactory pathway for training, accreditation and ongoing education of general practitioner anaesthetists.
Key Words: general practitioner anaesthesia, accreditation, workforce
In 2001, the Joint Consultative Committee on Anaesthesia (JCCA) introduced a new system of accreditation for general practitioner anaesthetists (GPAs) for the 2002-2004 triennium. It was hoped at the time that this would strengthen the accreditation process. The system would be based on the academic standard of the Advanced Rural Skills Curriculum Statement in Anaesthesia (ARSCSA) and would consist of two categories--accredited and enrolled.
The JCCA is a tripartite committee with representatives from Australian and New Zealand College of Anaesthetists (ANZCA), Royal Australian College of General Practitioners (RACGP) Rural Faculty and Australian College of Rural and Remote Medicine (ACCRM) (1). The current membership of the JCCA consists of four specialist Anaesthetists from ANZCA, two rural GPAs nominated by the RACGP Rural Faculty and two rural GPAs nominated by ACCRM. The JCCA is involved in training and accreditation of GPAs.
The ARSCSA is the basis for training of GPAS (2). The ARSCSA was developed by the JCCA and is now up to its third edition 2003. Training involves a 12-month position in a JCCA accredited post. Hospitals accredited for ANZCA training are automatically accredited and some smaller regional hospitals have been JCCA accredited. The learning objectives during this post are set out in the ARSCSA. After receiving a satisfactory report from the director of the training department, success is then required in a 60 minute viva voce examination with one Specialist Anaesthetist and one GP Anaesthetist. Case commentaries or a research project are also required. GPAs should also complete the Early Management of Severe Trauma (EMST) or Effective Management of Anaesthesia Crises (EMAC) courses. This is in accordance with ANZCAs Recommendation on Essential Training for Rural General Practitioners in Australia Proposing to Administer Anaesthesia Review PS1(2001) (3).
The MOPS program is the voluntary accreditation program of the JCCA. GPAs apply by completing the enrolment form and supplying evidence of their anaesthesia training, qualifications, recent caseload and curriculum vitae. GPAs will then either be:
Category A accredited--having satisfactorily completed the ARSCSA and examination or equivalent. Many existing GPAs have been administering anaesthesia prior to the introduction of the ARSCSA and have had their training and experience taken into account and been deemed equivalent.
Category B enrolled--not having completed the ARSCSA and examination or equivalent but are still needed to administer anaesthesia and want to be involved in continuing medical education.
GPAs in both categories will need to be involved in quality assurance and continuing professional development (QA&CPD), earning points via one of either RACGP's or ACCRM's QA&CPD program or ANZCAs MOPS program.
Few recent surveys are available for comparison. Watts and Bassham (4) surveyed 92 South Australian GPAs in 1992 of whom 76 responded. They administered an average of 152 anaesthetics per year; 87% administered anaesthesia at least once per week; 46% provided anaesthesia for 0-12 month age group and 33% administered epidurals. Watts and Bassham also quote in their article a New South Wales survey by Carrol and Collet in 1990 in which 190 GPAs were averaging 150 anaesthetics per year and a Queensland study by Khursandi where 80% of GPAs performed less than 150 cases per year. Another 1992 survey by Merefield is quoted by Watts and Bassham that found that in rural Queensland 80% of all anaesthesia is provided by GPAs.
Carleton surveyed Western Australian rural General Practitioners in 1996 (S. Carleton, unpublished observations), 25% of whom administered anaesthesia. There were 92 GPAs administering an average of 219 anaesthetics per year of which 191 were general anaesthetics; 65% administered epidurals; 2.8 years was the mean lower age for paediatric patients.
The purpose of this survey was to gain information regarding accreditation, continuing medical education, caseloads, on call, work practices, attitudes and future work plans. It is hoped this will increase understanding of the role of GPAs in Australia, especially in a political climate that is searching for providers of anaesthesia other than the traditional medical workforce.
MATERIALS AND METHODS
In January 2006 I surveyed all GPAs in Australia currently involved in the JCCA MOPS program. After gaining permission from the JCCA, the survey was sent via the JCCA Secretariat at the RACGP headquarters in Melbourne. All active participants in the JCCA MOPS program in Australia were sent a survey. A total of 240 surveys were sent. The author did not have access to the JCCA database or receive any identifying information regarding the GPAs. A prepaid return address envelope was included so GPAs could return the completed surveys to the author. The survey was a two-page questionnaire consisting of 23 questions. An accompanying introductory letter was sent with the questionnaire. The questions required a tick the appropriate box answer. For some questions the participants were requested to tick as many as apply. Participants were not requested to send any identifying details.
Response rate and work location
Two-hundred-and-forty surveys were sent of which 168 (70%) were returned. The majority of respondents were from Victoria (28%), New South Wales (26%) and Queensland (23%). There were smaller numbers from South Australia (14%), Western Australia (2%), Australian Capital Territory (1%), Tasmania (1%), Northern Territory (1%). There were a few (4%) who worked in multiple states.
The majority of respondents worked in a rural location (73%) usually in a mix of private and public sector (49%):16% worked in a regional centre, 7% in a variety of centres, whilst 4% worked in a metropolitan area. Thirty-nine percent of respondents worked only in the public sector.
Eighty-nine percent of respondents were category A accredited whilst 8% were category B enrolled: 3% were unsure or didn't answer. Fifteen percent of respondents had completed the ARSCSA and examination, whereas 77% were deemed equivalent.
The majority of respondents (52%) were enrolled with RACGP for continuing education whilst 39% were with ACCRM, 3% with ANZCA and 4% with multiple colleges. Figure 1 shows the activities undertaken. Clinical attachments, attending conferences and simulator courses were the most popular.
[FIGURE 1 OMITTED]
The mean number of sessions worked per week was 2.8 (SD 2.2). Nineteen percent of respondents reported they were never on call for anaesthesia. Of those who were on call, five to six times per month was frequently stated (16%): however, 28% stated they were on call greater than ten times per month. This may reflect the rural workforce situation.
[FIGURE 2 OMITTED]
Sixty-nine percent of respondents administered more than 150 anaesthetics per year, whilst 19% administered more than 500 anaesthetics per year.
Fifty-seven percent of respondents reported that general anaesthesia and/or regional anaesthesia comprised greater than 60% of their anaesthetic caseload. There were 14 (8%) respondents who stated that sedation comprised 81-100% of their caseload. Of these, seven listed gastrointestinal tract (GIT) endoscopy as the only specialty for which they provided anaesthesia. Another two listed GIT endoscopy plus thoracics and another listed GIT endoscopy plus thoracics plus ophthalmology. It is likely that these ten respondents are 'sedation only' practitioners. Of the 14 respondents who stated that sedation comprised 81-100% of their caseload, ten administered >500 anaesthetics per year. The vast majority of respondents (92%) stated they used propofol as part of their intravenous technique.
Surgical specialties which respondents provided anaesthesia for are demonstrated in Figure 3. The most frequently listed specialties were general surgery (87%), gastrointestinal tract endoscopy (75%), obstetrics (75%), gynaecology (73%) and orthopaedics (63%).
[FIGURE 3 OMITTED]
Ninety percent of respondents provided anaesthesia for paediatric patients. The mean minimum age of patient that they would anaesthetize for in an elective case was 4.1 years (SD 3.4), though 4% stated there was no minimum age for which they would anaesthetize for in an elective case.
Sixty-four percent of respondents administered epidurals for anaesthesia/analgesia. Of those, the range most frequently quoted was 11-25 epidurals per year (23%).
[FIGURE 4 OMITTED]
Membership of professional societies
Twenty-five percent of respondents stated they were associate members of the Australian Society of Anaesthetists. Two percent had used the Australian and New Zealand College of Anaesthetists Rural Anaesthesia Recruitment Service to obtain work.
The majority of respondents (74%) work in hospitals where there are no specialist anaesthetists. Nine percent of respondents stated there were greater than five specialist anaesthetists at their hospital.
GPAs were asked how they would agree or disagree with two statements. The results are shown in Table 1.
Future work plans
The majority of respondents (71%) plan to continue their current anaesthetic workload whilst 11% plan to increase it over the next five years. Seventeen percent of respondents plan to cease or reduce providing anaesthesia services. Figure 5 shows the potential issues that may result in GPAs ceasing to provide anaesthesia services.
[FIGURE 5 OMITTED]
Two-hundred-and-forty GPAs are currently participating in the JCCA MOPS program in Australia. This is a non-compulsory program and so there may be many more GPs providing anaesthesia services. The majority of respondents were from Victoria, New South Wales and Queensland. Although this may be expected, as these are the most populous states in Australia, there was notable absence of respondents from Western Australia (4). This may be due to The Department of Health in Western Australia previously establishing an accreditation program for GPAs via its Statewide Anaesthetic Reference Group. Despite the noncompulsory nature of the JCCA MOPS program, many hospitals are now requiring proof of JCCA accreditation prior to granting clinical privileges. Anaesthesia and Intensive Care, Vol. 34, No. 6, December 2006
The response rate was 70%. Whilst a response rate of greater than 60% for self-completion questionnaires is generally considered acceptable (5), a response rate of less than 100% may cause misleading results. There is the possibility of reporting bias with responders having a greater interest or involvement in anaesthesia.
It was not surprising that 49% of respondents work in both public and private sectors as this would reflect rural work settings where a large number of GPs would work in a private practice and provide services to public hospitals.
The majority of respondents (89%) are category A accredited while 77% of respondents have had their training and experience deemed equivalent. Only 15% have completed the ARSCSA and examination. This will hopefully change in the future now that there is an established curriculum and pathway for GPs to follow in order to gain JCCA accreditation that did not exist in the past for existing practitioners. Doctors need not be enrolled in GP training to undertake the ARSCSA and examination and can become JCCA registrars without being enrolled in any particular college training program.
More respondents were enrolled with RACGP for continuing education with ACCRM close behind. Only six respondents were enrolled with ANZCA. Of the six that were enrolled with ANZCA, three worked eight or more sessions per week in anaesthesia. ANZCA MOPS may be more suited to those GPAs who work full-time in anaesthesia.
Clinical attachment, attending conferences and simulator courses were the most popular activities. GPAs have at times complained of difficulties arranging clinical attachments but clearly the majority (70%) of respondents have been able to. Of interest is the popularity of simulator courses with 69% of respondents attending. Some simulator centres are offering courses specifically directed towards rural GPAs.
The question of adequate caseload to maintain skills has been discussed in the past. The JCCA sets no specific number of anaesthetics administered per year to maintain accreditation. Previous surveys have shown average numbers around 150-200 anaesthetics administered per year. This survey showed that 69% of respondents were administering more than 150 anaesthetics per year and 19% administering more than 500 anaesthetics per year at an average of 2.8 sessions per week. The increasing number of sedations for GIT endoscopy may account for increasing numbers of anaesthetics administered by GPAs. However, only 14 respondents stated that sedation comprised more than 80% of their caseload. For the majority of respondents (57%), general and regional anaesthesia comprises the bulk (61-100%) of their anaesthetic caseload.
On call requirements for rural practitioners can be onerous with 28% of respondents stating they were on call more than 10 times per month. On call requirements was stated as a reason for considering ceasing to provide anaesthesia services. This is particularly a problem if the GPA is faced with a reduction in elective lists with the resultant deskilling and yet still expected to deal with the complexities of emergency cases.
There has been recent discussion about the use of propofol for sedation and who should use it. Conscious sedation results in a depressed level of consciousness; however, the patient can still respond purposefully to verbal command or light touch. As sedation deepens and progresses to general anaesthesia the patient may lose the ability to maintain a patent airway, airway reflexes are depressed, spontaneous ventilation may be inadequate and cardiovascular depression may occur. This is much more likely with the use of intravenous anaesthetic agents such as propofol. The ANZCA document PS24 (2004) (6) Guidelines on Sedation for Gastrointestinal Endoscopic Procedures states that "If anaesthetic agents such as propofol are used, a medical practitioner trained in the use of these agents must be present to exclusively care for the patient". Clarke et al (7) published a paper on "The safe use of propofol by GP sedationists" which furthered discussion on the subject. This survey shows that the vast majority of respondents (92%) used propofol as part of their usual intravenous sedative technique.
Sixty-four percent of respondents administered epidurals. This was comparable with the 1996 survey of Western Australian GPAs (65%). Seventy-five percent of respondents stated they provide obstetric anaesthesia. The ARSCSA allows for optional endorsement for epidural anesthesia.
The ARSCSA usual minimum paediatric age is three years with optional endorsement down to 12 months. The mean age for elective cases was 4.1 years in this survey. This age is higher than the mean of 2.8 years in the 1996 survey of Western Australian GPAs. Only 4% of respondents stated they had no minimum age compared with the 1992 South Australian survey in which 46% of GPAs were happy to provide anaesthesia for the 0-12 month age group.
Respondents provided anaesthesia for a wide range of surgical specialties, general surgery, GIT endoscopy, obstetrics, gynaecology and orthopaedics being the most common. Elective neurosurgery and thoracics are not part of the ARSCSA, although similar principles are applied to emergency cases. It is likely that those listing thoracics were providing sedation for bronchoscopy.
Only 25% of respondents were associate members of the Australian Society of Anaesthetists. A number of respondents mentioned they previously had been members, perhaps suggesting a recent decline in membership of GPAs. The ANZCA Rural Anaesthesia Recruitment Service (RARS) has been used by only three of the respondents to obtain work. RARS is aimed not only at specialist anaesthetists but also JCCA accredited GPAs; however, most positions advertised appear to be for specialists.
Overall, there was support for GPAs both from specialist anaesthetists and hospital administrations. Several respondents indicated that some individuals were supportive whilst others were not. With the majority of respondents (74%) working in hospitals where there were no specialists anaesthetists, being able to get advice from specialist colleagues is important. There appeared to be no association between the number of specialists working at the respondent's hospital and their rating of support. Cooperation and support between specialists and GPAs is the ideal situation for rural centres with the benefits for specialists having GPAs to share the on call arrangements and GPAs having specialist support for advice and difficult cases.
The majority of respondents (82%) plan to continue or increase their current anaesthetic workload over the next five years whilst 17% plan to stop or reduce their anaesthetic workload. Politics, continuing medical education/time issues featured prominently (as issues) whilst the introduction of nurse anaesthetists was the least frequently stated issue. Other potential issues listed by respondents included inadequate caseload to maintain skills, severe adverse events, closure of operating theatre, surgeon retiring, better remuneration working in GP rooms, on-call requirement, the JCCA and personal life.
I wish to thank Ms Pam Garrard, JCCA Secretariat, RACGP, for her time and effort involved in the mail out of this survey. Thanks also to all the GPAs who participated in this survey.
Accepted for publication on August 14, 2006.
(1.) Royal Australian College of General Practitioners. Joint Consultative Committee on Anaesthesia. From http://www.racgp.org.au/document.asp?id=1952 Accessed April 2006.
(2.) Royal Australian College of General Practitioners. Advanced Rural Skills Curriculum Statement in Anaesthesia. From http:// www.racgp.org.au/downloads/pdf/ARSCSA2003.pdf Accessed April 2006.
(3.) Australian and New Zealand College of Anaesthetists. Recommendations on essential training for rural General Practitioners in Australia proposing to administer anaesthesia. Review PS1 (2002). From http:/www.anzca.edu.au/pdfdocs/ PS1_2002.PDF Accessed April 2006.
(4.) Watts R, Bassham M. Training, Skills and Approach to Potentially Difficult Anaesthesia in General Practitioner Anaesthetists. Anaesth Intensive Care 1994; 22:706-709.
(5.) Jones D, Story D, Clavisi O, Jones R, Peyton P An introductory guide to survey research in anaesthesia. Anaesth Intensive Care 2006;34:245-253.
(6.) Australian and New Zealand College of Anaesthetists. Guidelines on sedation for gastrointestinal endoscopic procedures. Review PS24 (2004). From http://www.anzca.edu.au/pdfdocs/PS24_2004.PDF Accessed April 2006.
(7.) Clarke AC, Chiragakis L, Hillman LC, Kaye GL. Sedation for endoscopy: the safe use of propofol by general practitioner sedationists. Med J Aust 2002; 176:158-161.
M. J. DAVIE *
Department of Anaesthesia, Logan Hospital, Brisbane, Queensland, Australia
* M.B., B.S., Provisional Fellow.
Address for reprints: Dr M.Davie, PO Box 1153, Coorparoo DC, Qld. 4151.
Table 1 Question % agree % disagree or strongly or strongly agree disagree Specialist anaesthetists are helpful 66 13 and supportive of me in my anaesthetic practice Hospital(s) administrations are 64 14 helpful and supportive of me in my anaesthetic practice
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|Publication:||Anaesthesia and Intensive Care|
|Date:||Dec 1, 2006|
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