Evidence from the GP Synergy NSW & ACT Research and Evaluation Unit – each month we present findings from our work that may be of interest to registrars and their supervisors.
In an analysis of registrars across five Australian states plus the ACT, conducted within the Registrar Clinical Encounters in Training project, we explored registrars’ pathology test-ordering.
Pathology testing is a vital component of a GP’s practice. It is essential for screening, diagnosing, and monitoring disease. The increasing range of pathology tests available to GPs (and registrars) reﬂects technological advances and increased understanding of disease processes. An expansion of test ordering (i.e. tests ordered more frequently) may thus be appropriate. But inappropriate ordering is a major issue in Australian health-care, including in general practice: not only does it contribute significantly to health-care costs, it can result in over diagnosis with subsequent over treatment.
We calculated the number of pathology tests registrars requested per consultation. We then compared this frequency of test-ordering by registrar term. Registrars emerge from a high disease prevalence environment (hospital practice) with pathology-testing habits framed within that context. With previous evidence also suggesting that a clinician’s clinical uncertainty was a prominent driver of pathology test ordering, we hypothesised that test-ordering would decrease with increasing registrar seniority/experience.
Contrary to our expectations, the number of pathology tests requested (when adjusted for other factors) increased by 11% (P < 0.001) per training term. This interesting finding raises questions. It may be that, as registrars take on increasing responsibility for overall patient care, their increasingly active management role involves more pathology testing. This may be so especially for older patients, patients with chronic disease, and more complex ‘difficult’ patients. We also know from this and a previous ReCEnT analysis that seeking in-consultation assistance or advice, including from a supervisor, is associated with less pathology test-ordering.
The limitation of our study is that we don’t know the context of individual test-ordering decisions – whether an individual test was ‘appropriate’ or ‘inappropriate’. This is a topic that is very suitable for further research.
In the meantime, a practical application of the findings is that we should continue to support registrars in their rational test-ordering practice. We encourage registrars to have a teaching session with their supervisor about rational test ordering (an inbox review is a good way to do this), senior registrars should strongly consider asking supervisor advice about their more complex test-ordering decisions.
- Magin P, Morgan S, Tapley A, Henderson K, Holliday E, Ball J, Davey A, Catzikiris N, Mulquiney K, van Driel M. Temporal changes in early-career general practitioners’ pathology test – ordering behaviour in an Australian longitudinal study. 2017. Medical Journal of Australia. 207(2): 70-74. doi: 10.5694/mja16.01421
- Morgan S, Coleman J,, van Driel M, Magin P Rational test ordering in family medicine Vol 61: june • juin 2015 | Canadian Family Physician • Le Médecin de famille canadien
- GPSA – Rational test ordering in general practice
- Investigate an interactive website designed for use by medical graduates, which focuses on the appropriate and cost-effective use of diagnostic investigations.
Or contact Parker Magin if you would like further information.