Trust me, I’m a GP

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Here at DFTB we are keen to promote a culture that breaks down the silos of who can do what. We all care about one thing, above all else, the wellbeing of the children we treat. Working in a hospital environment sometimes gives us a skewed view of illness. Just like every neurosurgeon that sees a patient with a headache is concerned about a sub-arachnoid haemorrhage, every doctor in the paediatric emergency department is concerned about missing sepsis.

With winter (in the south) dragging on, we are seeing more and more children in the emergency department. It has become so bad that some hospitals are even sending out tweets suggesting patients get taken elsewhere. Why not their general practitioner?

Today I’m going to take a look at the following paper and its controversial conclusions.

Freed GL, Spike N, O’Hara J, Hiscock H, Rhodes AL. National study of parental confidence in general practitioners. Journal of Paediatrics and Child Health. 2017 Sep 3.

 

How was it performed?

A representative sample of 2100 Australians  completed an online survey. They had to act as caregivers for a child under the age of 17, live in Australia and have internet access. This sample group was taken from a larger research panel of over 120,000 Australians and was distributed across the states in proportion to the population. The survey was anonymous and incentivized to improve completion rates.

 

What were the results?

Whilst there are days when I think every child in the neighbourhood has been brought to our ED the survey results suggest that a whopping 93% of caregivers take their child to the GP.

Putting that in perspective it means that if, in a 10 hour shift, I see 8 children with a cough, cold or runny nose that I think could have gone to to their GP another 194 are being cared for by general practitioners.

But were the parents happy with the advice they received? 

When it comes to minor illness 89% (1884 of 2100) respondents were either mostly or completely confident in the health care provider. A similar number (89%) were also confident that their GP could handle a minor injury or two.

So what did the authors conclude?

The authors concluded that fewer than 44% of parents expressed complete confidence in their GP in dealing with general health issues for their child. A regression analysis revealed that lower levels of confidence were associated with younger parents and a higher level of attained education whereas increased confidence was associated with older parents and visiting a regular GP.

What has the media said?

A clickbait ad-driven press reads the abstract and misses the raw data. Table 2 (reprinted above) clearly states that only 4% of parents bypass their GP’s and go straight to the ED.

What do I think?

Whilst I think the paper asks some interesting questions I would reframe the conclusion around the fact that 89% of parents are mostly confident that their GP knows what they are doing. Freed et al. argue the semantics of the term complete confidence suggesting that parents who are not completely confident might be more inclined to present to the emergency department I would like to know the baseline level of complete confidence in all doctors.  

There has been an increase in the number of children presenting to the ED and it is important to drill down and find out why, especially when so-called low acuity cases are on the rise. An earlier survey, carried out by Freed, of four metropolitan hospitals in Victoria (one of which was a tertiary paediatric centre) showed that only 43% of parents had attempted to make an appointment with a GP prior to attendance. When asked why they went to hospital it seemed that the majority (94%) of the parents felt that their child had a serious condition. There is clearly a disconnect between what a parent thinks is serious (and thus warrants hospital attention) and what a triage nurse or treating doctor thinks is not serious (and thus should have gone to the GP).

Borland et al. also point out some possible inconsistencies with the use of triage category as a surrogate marker for acuity. A child with persistent bruising and lethargy may be given a triage category of 4 or 5 marking them as low acuity but their underlying diagnosis of leukaemia would never be classified as low acuity. Triage categories provide arbitrary time based targets in which patients should be seen and may not reflect the underlying seriousness of their condition. If you look at the Australian Institute of Health and Welfare (AIHW) definition of a low acuity GP-type patient you can see the problem…

….as one who did not arrive by ambulance/police/correctional vehicle, was not admitted, had a triage category 4 or 5, was not referred to another hospital and did not die.

What none of the papers provide is outcome data. I would be interested to know what exactly the themes across the low-acuity presentations were and what were the outcomes of those visits in terms of processes that cannot be readily performed in a busy general practice (blood tests, radiographs, ultrasounds) and admissions.

Other studies of child attendances also highlight that one of the major drivers for attendance is not lack of confidence but parental perceived seriousness. How one changes a culture is then up for debate.

References

Freed GL, Spike N, O’Hara J, Hiscock H, Rhodes AL. National study of parental confidence in general practitioners. Journal of Paediatrics and Child Health. 2017 Sep 3.

Freed GL, Allen AR, Turbitt E, Nicolas C, Oakley E. Parent perspectives and reasons for lower urgency paediatric presentations to emergency departments. Emergency Medicine Australasia. 2016 Apr 1;28(2):211-5.

Turbitt E, Freed GL. Paediatric emergency department referrals from primary care. Australian Health Review. 2016 Dec 21;40(6):691-5.

Borland M, Skarin D, Nagree Y. Comparison of methods used to quantify general practice‐type patients in the emergency department: A tertiary paediatric perspective. Emergency Medicine Australasia. 2017 Feb 1;29(1):77-82.

Cheek JA, Braitberg G, Craig S, West A. Why do children present to emergency departments? Exploring motivators and measures of presentation appropriateness for children presenting to a paediatric emergency department. Journal of Paediatrics and Child Health. 2017 May 1;53(5):451-7.

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About 

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew’s DFTB posts

Author: Andrew Tagg

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew’s DFTB posts

One Response to "Trust me, I’m a GP"

  1. Mark Raines
    Mark Raines 3 months ago .Reply

    Great assessment but unlikely to grab enough attention to buy advertising time for the media.