PROFESSIONAL PRACTICE E A Farmer BSc, MBBS, PhD, FRACGP, is Dean, Graduate School Medicine, University of Wollongong, New South Wales. D O’Halloran MBBS, FRACGP, MHPEd, FAICD, is Associate Professor of General Practice, University of Sydney, and Chair, The Royal Australian College of General Practitioners NSW&ACT Faculty. J P Sturmberg MBBS, MFM, PhD, FRACGP, is Associate Professor of General Practice, Monash University, Victoria and University of Newcastle, New South Wales. jp.sturmberg@gmail.com ABLE – assessment based learning The complexities of clinical practice Primary medical care is provided in very diverse environments that define patient needs and expectations as well as a doctor’s actual, expected and potential scope of practice. 2 The GP’s learning needs are determined by the information explosion, a diversity of clinical environments and the public’s increasing expectations of accountability. General practitioners must therefore have the capacity to adapt to these challenges. Their resulting learning needs however may be difficult to meet in full due to: workforce and workload pressures, constrained local educational infrastructure, inadequate characterisation of the practice population and therefore its health needs, and importantly, every GP’s limited ability to judge accurately his/her own learning needs. Thus the profession is confronted with competing but co-existing and connected agendas. Such a situation is best understood through a complex adaptive systems (CAS) model. A CAS consists of many different components that interact in a nonlinear way. These interactions occur at many different levels, and influence each other through feedback loops. Interactions are not determined by the characteristics of the components themselves, but rather by the patterns of their interactions: these are the defining characteristic of such a system. Inevitably, complex adaptive systems are dynamic in that they change over time – based on the flow of energy, information and adaption. 3 A framework solution The Royal Australian College of General Practitioners (RACGP) has long recognised the challenges of changing general practice realities. Their quality framework, 4,5 developed in 2005, illustrates the complexity of linked system interactions – from health policy formulation through to individual physiology, that go to make up quality care and the patient’s experience of health. 6 Continuing formal and informal discussions among many committed members of the discipline have helped to crystallise the main issues facing the profession in terms of ongoing assessment and targeted education, leading to a potential solution. Over the past decade the Australian health care system has moved rapidly toward a greater emphasis on medical care being provided within the community. 1 This trend can only continue as our population ages and levels of chronic and complex illness continue to rise. Primary care now includes: • a higher proportion of general practitioners working in group practices supported by practice nurses and allied health professionals – both on site and in the community • increased patient presentations for chronic and complex disease – often compounded by mental health and social issues, and • more hospital in the home, early discharge and similar programmes enabling shared management of sicker patients in the community. These changes mean that the already comprehensive core skills of general practice have further expanded, added to which is an increased need for rapid and effective acquisition of new skills throughout a professional lifetime. Initial assessment of core competences at the point of entry into unsupervised general practice is already a statutory requirement. However, the assessment of ongoing capabilities and performance (a measure of professional standards in practice and public accountability) requires quite different approaches to professional education and assessment. Challenges How do we adapt to the new demands on general practice? And how do we best help GPs to maintain and extend their skills to provide patients with appropriate care and excellent personal health experiences? The challenges of changing education and assessment requirements have been compounded by the changing nature of the general practice workforce, with increasing numbers of international medical graduates entering general practice, with variable understanding or experience of the Australian primary care system. 860 Reprinted from AUSTRALIAN FAMILY PHYSICIAN Vol. 37, No. 10, October 2008