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Trust me, I’m a GP


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 well-being of the children we treat. Working in a hospital environment sometimes gives us a skewed view of illness. Like every neurosurgeon who sees a patient with a headache is concerned about a sub-arachnoid haemorrhage, every doctor in the paediatric emergency department is worried 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 even send tweets suggesting patients get taken elsewhere. Why not their general practitioner?

Today I will 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 more extensive research panel of over 120,000 Australians and was distributed across the states in proportion to the population. The survey was anonymous and incentivised 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 93% of caregivers take their child to the GP.

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

But were the parents happy with the advice they received? 

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

So what did the authors conclude?

The authors concluded that fewer than 44% of parents expressed complete confidence in their GP dealing with their child’s general health issues. A regression analysis revealed that lower levels of trust were associated with younger parents and a higher level of attained education. In contrast, 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 GPs and go straight to the ED.

What do I think?

Whilst the paper asks some interesting questions, I would reframe the conclusion around the fact that 89% of parents are 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 entirely sure 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 therefore 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 like to know the themes across the low-acuity presentations and the outcomes of those visits regarding processes that cannot be readily performed in a busy general practice (blood tests, radiographs, ultrasounds) and admissions.

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


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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