Utility of advanced training skills among GPs: a systematic review

Introduction: Advanced Skills Training (AST) is designed toprovide GPs with an opportunity to enhance their clinical practicein a narrower speciality. This is valuable particularly for rural andremote communities that cannot justify narrower specialist servicesin the local community. ASTs require additional focused training,usually for 12 months, in a selected procedural or non-proceduralskill such as anaesthetics, obstetrics, surgery, emergency medicine, paediatrics, adult internal medicine, mental health, Indigenous health or palliative care. Ideally, several practitioners with complementary AST experiences work together to provide a widerrange of extended scope practice according to community need. However, experience so far suggests that this goal is notnecessarily achieved. Thus, this systematic review aimed to assessthe value and fitness for purpose of AST and ensure that it ismeeting the growing demand for coordinated care in rural communities. This review addressed three questions: What is theeffectiveness of AST programs in improving GPs’ knowledge,attitudes and competence regarding rural clinical practice? How do stakeholders – including trainees, patients, management and the community – perceive the impact (value and fitness for purpose) ofthe AST program in rural clinical practice? To what extent are advanced skills training programs aligned with the needs of the community served? Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search strategy was implemented across six electronic databases (Medline Ovid, CINAHL, Emcare, Scopus, Web of Science and Informit) in December 2024. The quality of the studies was appraised using the Quality Assessment for Diverse Studies tool. Across all there viewed articles, data on the effectiveness of AST, stakeholder perceptions of its value and extent of alignment of AST with community needs in rural clinical practice were extracted and synthesised using a data extraction template. Results: Sixteen peer-reviewed articles met the inclusion criteria. Of these, 11 employed qualitative study designs (n = 11, 68.8%) and five were quantitative (n=5, 31.3%). The majority were conducted in Canada (n=5, 31.3%) and Australia (n=5, 31.3%), followed by the US (n=4, 25.0%) and England (n=2, 12.5%). The findings revealed that the definition and scope of AST varied across the literature. Some defined it as advanced training that involves 12 months full-time equivalent in an accredited training post while others definedit as ‘tracks’, certificates, extended fellowships, residency programs or placements. Across the literature, participants note dimprovements in their knowledge, attitudes and competence regarding their clinical practice. The value and fitness for purposeof the AST program was demonstrated by registrars’ continued useof skills after AST training, soft skills development and community engagement opportunities, and rural workforce retention. The challenges reported for those undertaking AST programs were barriers to inclusion on remote visits (eg transportation space, training space), time efficiency and management, work loadfluctuation, gaps between training and use of skills, peerac knowledgement, and differences between the hospital settings in which training occurred and the rural contexts in which the skillswould be applied. Conclusion: Overall, this review provided evidence on the utility of AST for GPs. Despite the value of AST in GP clinical practice, some bottlenecks may be limiting its effectiveness. Current AST opportunities (both training and final practice location) and career pathways are not always aligned, potentially limiting the success ofthe AST strategy in bridging the gap between urban and rural health service status. Concerted efforts are required to improve alignment of career advice, community needs, training pathways, AST opportunities and final practice location in order to achieve the intended purpose. Further research is required on the impact of AST programs on community health outcomes.

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