Utility of advanced training skills among general practitioners: a systematic review

Introduction: Advanced Skills Training (AST) is designed to provide general practitioners with an opportunity to enhance their clinical practice in a narrower speciality. This is valuable particularly for rural and remote communities that cannot justify narrower specialist services in the local community. ASTs require additional focused training, usually for 12 months, in a selected procedural or non-procedural skill 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 wider range of extended scope practice according to community need. However, experience so far suggests that this goal is not necessarily achieved. Thus, this systematic review aimed to assess the value and fitness for purpose of AST and ensure that it is meeting the growing demand for coordinated care in rural communities. This review addressed three questions: a) What is the effectiveness of AST programs in improving general practitioner’s knowledge, attitudes, and competence regarding rural clinical practice? b) How do stakeholders, including trainees, patients, management, and the community, perceive the impact (value and fitness for purpose) of the advanced specialised training program in rural clinical practice? c) 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 (QuADS). Across all the reviewed 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 United States (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 defined it as ‘tracks’, certificates, extended fellowships, residency programs, or placements. Across the literature, participants noted improvements in their knowledge, attitudes, and competence regarding their clinical practice. The value and fit for purpose of the AST program was demonstrated via registrars continued use of 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 (i.e. transportation space, training space), time efficiency and management, workload fluctuation, gaps between training and use of skills, peer acknowledgement and differences between the hospital settings in which training occurred and the rural contexts in which the skills would be applied.
Conclusion: Overall, this review provided evidence on the utility of AST for GPs. Despite the value of AST in GPs clinical practice, there are some bottlenecks that 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 of the 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.
Keywords: advanced skills training, certificate, general practitioner, rural, remote, systematic review, vocational training.