Educating general practitioners: are we preparing them for cost-conscious care?

Explicit training in appropriate decision making about pathology test ordering should be provided early

Developing a training framework that fosters and cultivates a lifetime approach to high value and cost-conscious health care is challenging. High value health care has been defined as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”1 In this issue of the MJA, Magin and colleagues report their analysis of the recorded information for almost 115 000 consultations by 876 general practice registrars in Australia.2 During the first 18–24 months of clinical practice, the number of pathology tests they requested increased by 11% per 6-month full-time equivalent term. This significant increase early in clinical practice is worrying; general practitioners request pathology tests more frequently than other medical practitioners,2 and establishing good patterns of decision making in the formative years of clinical training should be a priority.

The reasons for this substantial increase in test ordering are not entirely clear, and herein lies the complexity of developing the ideal educational program that tackles the problem. With increasing time in clinical practice, general practice registrars seek less advice from supervisors, and the evidence suggests that greater supervisor input is associated with lower rates of pathology test ordering.3 It is also possible that, as the experience of general practice registrars increases, they manage more complex patients. A further factor is that they have recently left hospital environments in which comprehensive pathology testing was normal. Somewhat more subtly, the test ordering behaviour of general practice registrars may simply reflect that of their supervisors and practice pathology test ordering behaviour overall.4

Morgan and Coleman have commented on the increase in pathology test ordering by GPs, the lack of an evidence-based approach to ordering, and the unanticipated effects of inappropriate testing on patients, such as high false positive rates.5 Improving the quality of pathology test ordering is a clear national policy priority, as indicated by the Quality Use of Pathology (QUPP) program of the federal government: “there is a continued commitment to providing support for initiatives that improve patient care through enhancing the quality of pathology services and the appropriate use of services.”6 Review of the completed and current projects on the QUPP website disclosed that none focused on GP education.

The importance of general practice registrar training for imprinting future behaviours and decision making cannot be underestimated.5,7 A review of the Royal Australian College of General Practitioners’ point of fellowship competencies identified that the “effective use of resources” and acting in a “cost-conscious” manner are among the core competencies required of GPs.8 There is evidence that changes in pathology test ordering behaviour and cost savings can be achieved by appropriate training.9 Chen and colleagues reported an innovative American study that compared mean Medicare spending per beneficiary (including pathology test ordering) by a randomly selected national sample of family physicians and internal medicine physicians, who were stratified into low-, average and high-spending regions of training and subsequent practice. During the first 1–7 years after completing training, there was a 29% difference in Medicare spending between low- and high-spending practice clinicians, but by 16–19 years there was no significant difference.9

How should we tackle what is essentially the imparting of a new competency? Stammen and colleagues found that being trained in how to assimilate information about costs, clinical evidence, and patient preferences, and integrating audit and feedback models into training programs and supportive practice environments, were all significant influences on behaviour.10 More specific practice-based strategies could include random case note analysis, auditing of pathology inbox results, consultation observation, application of clinical guidelines, the efficient use of online resources,5 and longitudinal analyses of aggregated Medicare data. However, the evidence base is weak and depends on small, non-generalisable study findings.10 Achieving a balance between the cost implications of inappropriate pathology test ordering and choosing the most appropriate test will be increasingly important in any educational innovation;1 ie, selecting pathology tests that do not cause patients unintended harm. The importance of the clinical environment and of role models4 at this pivotal time in the development of clinical behaviour means that, if we are serious about facilitating cost-conscious care, we also need to consider aligning the behaviour of general practice supervisors with these aims, possibly including formal training in these skills.

Designing a general practice registrar education model that embraces the complexity of cost-conscious care is difficult.1 I agree with Magin and his co-authors2 that the ideal place to start decisively tackling this educational and clinical priority is in the real world of general practice training.