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AT an educational meeting for GPs that I attended, the sponsor of the program said about one of the activities being promoted: “We want GPs to remember to do this when they are seeing patients.”
How often have you heard this, and how often do you read that GPs are failing to diagnose or to appropriately treat patients who have a particular, often rare, condition?
Many government-funded charitable and commercial organisations seek to educate and inform GPs about care that they should be providing and about new developments in general practice care.
Some of these organisations are focused on a particular disease, condition or phase of life, while others focus on the care that should be offered to particular subgroups of patients who might have or might be at high risk of a particular condition.
These subgroups are characterised by varying combinations of age, gender, personal medical history, family history, location, income status, and ethnic, racial or cultural background, and many of them are quite small.
Every special interest organisation wants GPs to remember to perform assessments or diagnostic tests or to offer particular treatments or other care that that organisation believes are relevant.
Special interest organisations spend significant proportions of their budgets on sending GPs printed materials, creating websites and organising educational meetings.
Why does all of the effort expended by special interest organisations have apparently small effects on GPs’ behaviour?
One reason is that any one condition, which seems common to an organisation that is focused on that particular disease, and caring for people with that condition makes up only a small proportion of each GP’s workload.
For example, diabetes is perceived as a very common chronic health problem, but in 2011–12 only 5% of adult Australians were diabetic, and Australian GPs report that they manage diabetes in only 3.7 of every 100 encounters.
Ovarian cancer, which despite being much less common than diabetes has nevertheless been prominent in the professional and lay media, was diagnosed in 1226 Australian women in 2006. This means that of the approximately 24 000 GPs in Australia, about one in 20 had a patient newly diagnosed with ovarian cancer in that year or, in other words, each GP on average can expect to have a patient newly diagnosed with ovarian cancer only once every 20 years, which amounts to once or twice in the GP’s career.
The low prevalence of any one condition among the patients GPs see daily makes it difficult for GPs to remember to perform the specific activities relevant to that condition or type of patient.
A second reason is that the agendas of consultations in general practice are crowded with matters that patients wish to discuss, and with items that the GP feels need to be addressed, including follow-up of known problems, indicated preventive activities and consideration of whether the patient may be eligible for and benefit from new programs or schemes.
After patient and GP have worked their way through both agendas, little time or energy remains for the GP to “remember” whether any of the special assessments, diagnostic tests or treatments recommended by the many organisations might be relevant for the patient.
What can each organisation interested in a particular disease or in the care of a subgroup of patients do to increase the likelihood that GPs will “remember” to perform the activities that it recommends?
First, almost all GPs now do most or all of their work within their electronic clinical record systems. These systems can remind GPs about care which may be indicated for the particular patient being seen.
The (non-GP) authors of a recent review of the prevalence of rare diseases only hinted at this when they said: “GPs cannot expect to have detailed knowledge of even a fraction of the huge number of known rare diseases, and these cannot be adequately covered in undergraduate or postgraduate medical training … Our challenge is to enable GPs and other clinicians to have easy access to accurate, locally relevant information that will assist them in making an early diagnosis, providing optimal management and support”.
It has been pointed out that: “Individual health workers, unable to ever read or master the growing biomedical literature … will be ever more reliant on … using intelligent computational systems to retrieve, synthesise and then act upon the distributed human knowledge base”.
Opportunistic reminders displayed to GPs on screen during the consultation have been found to have the largest and most consistently positive effects in changing GPs’ behaviour (here, here, here, here and here).
Most of the clinical software packages marketed for use in Australian general practice offer reminders for some of the preventive and disease care activities recommended by special interest organisations. However, the range and sophistication of these reminders is often rather limited.
These limitations have led to the development of specialised third-party software that links to GPs’ clinical software packages and that aims to provide a wider range of more sophisticated alerts and reminders.
Two major benefits of opportunistic reminders are that they cost nothing to run and they keep reminding the GP in every consultation until some action has been taken.
Patients have the greatest vested interest in their own health. They want their doctors to advise them about care that is indicated for them, but report that they are not receiving this advice.
Our research program is exploring the value of giving patients automatically-generated personalised targeted education, information and advice when they arrive for consultations, on which they can act immediately with no or minimal extra time, effort or cost (here and here).
All organisations that develop educational materials for GPs should also devote some of their resources to encouraging and facilitating the incorporation of relevant reminders into GPs’ clinical software.
The organisations can provide the algorithms that will drive the desired reminders, and can sponsor the development of modules that contain these algorithms and an application programming interface that enables vendors of clinical software packages to link to them without having to write and maintain their own code.
If you are part of an organisation that is interested in improving the care of subgroups of the population or people who have or are at risk of a particular disease, my message is this:
If you hear yourself or others in your organisation saying “we want GPs to remember to …”, please translate this to “we will sponsor practical help that reminds GPs about …” and use this as a cue to contact Josephine Raw, the General Manager of Practice Innovation and Policy of the Royal Australian College of General Practitioners, to discuss how your organisation can supply the practical help that GPs need to be able provide quality care for the people that your organisation serves.
Dr Oliver Frank is a university senior research fellow in the discipline of general practice at the University of Adelaide. He is also a practicing GP.
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