GP registrars lean more heavily on pathology testing as their training progresses, researchers have found
GP registrars are given more autonomy as they gain experience in practice, with the expectation that they will order fewer, more-targeted pathology tests as their knowledge base grows.
But researchers at the University of Newcastle were surprised to find that the opposite occurred with GP registrars leaning more heavily on pathology testing as their training progressed.
The study, which examined around 110,000 individual consultations from over 850 registrars around Australia, found pathology testing rose 11% for each of the three compulsory training terms.
Registrars that consulted with supervisors ordered fewer tests, the analysis showed. At least one pathology test was ordered in 23% of consultations.
The study did not contain data on the appropriateness of the test-ordering decisions. But more pathology testing was likely to entail an increase in unsuitable testing, the researchers said.
“It is possible that the uncertainty inherent to increasingly independent decision making by more senior registrars (i.e., with less supervisor assistance) leads to more ordering,” the researchers said.
“I think it is drawing a very long bow to make a lot of the conclusions,” Dr Melanie Smith, the President of GP Registrars Australia, said. “We really have no idea whether the testing is inappropriate.”
Perhaps more experienced GP registrars were more comfortable ordering tests prior to specialist referral, Dr Smith suggested. Or registrars could be taking on more new patients over time, or simply have greater knowledge about the range of tests available.
The researchers said another explanation for the findings could be that more-experienced registrars treated more-complex disease, leading to a rise in pathology testing over time.
The study left many questions unanswered, Dr Smith said.
But she welcomed research that prompted more reflective practice around pathology testing. “It would be interesting to know more,” she said.
Establishing good pathology-testing behaviours during the early years of clinical training should be a priority, Professor Justin Beilby, Vice-Chancellor at Torrens University and an academic specialising in primary care, said.
It was difficult to tease out the complex factors contributing to an increase in pathology testing, he said. It could be that GP registrars continued habits established during their time working in hospitals, where severe disease was more prevalent.
Alternatively, the test ordering behaviour of GP registrars might simply reflect that of their supervisors, he said.
“There is clear evidence that GPs order a broad set of tests without sometimes focusing on the specific questions they are asking,” Professor Beilby said. “My view is there is probably over-ordering of pathology testing.”
Professor Beilby said one way to cut unnecessary pathology testing would be to conduct audits. Under this system, the specific pathology tests ordered by GP registrars would be routinely recorded and judged against clinical guidelines.
“And then further discussion would be had with the registrar to say, ‘Why did you order this test when there is no real reason to do it?’ So you start a quality assurance cycle,” Professor Beilby said.
Other potential reforms included changes to the curriculum, consultation observation, application of clinical guidelines, the efficient use of online resources and longitudinal analyses of aggregated Medicare data, he said.
“Whether it will happen, who knows? It’s money and time and policy. But you have to start the conversation somewhere, and use data to drive it.”
Dr Smith said she would like to see GP registrars have greater access to supervision when they needed it, but added there was limited financial support available for this to occur.
Currently, GP supervisors are paid to offer three hours a week of training to a first-term GP registrar. This drops to 1.5 hours in the registrar’s second term, and there is usually no supervision payment for the third term.
MJA 2017, 17 July
