A new study backs what GP supervisors have been saying for years, writes Dr Steve Holmes.

A longitudinal study of pathology test ordering by GP registrars, published in the Medical Journal of Australia this month, is interesting in a curious kind of way.

The authors were surprised to find that rates of test ordering increased 11% through each term of a registrar’s training.

Perhaps, they conclude, registrars have too much clinical independence through the latter stages of their training. Maybe increased supervision would be a solution.

This backs what GP supervisors have been saying for years: registrars’ need for teaching and supervision as they progress through their training is not a straight-line path.

At some points in their later training, registrars need more teaching and supervision, not less. And supervisors need to be supported to deliver better outcomes.

This is particularly the case as they move to more independent practice as a senior registrar.

For 20 years we have been in stasis.

Firstly, government funding for GP supervisor teaching hours has remained static on a declining basis.

Secondly, few Regional Training Organisations fund dedicated teaching after a registrar’s first year of training.

What does this mean in practice?

It means GP supervisors are paid for just three hours per week to teach a GP registrar in their first term (first six months) and just 1.5 hours per week in their second term (second six months).

In terms three and four, GP supervisors generally aren’t paid at all.

GP Supervisors Australia recently met with Federal Minister for Health Greg Hunt and his ministerial colleagues Dr David Gillespie and Ken Wyatt.

The key message we delivered was that a poorly trained GP registrar delivers a costly blow to the Australian healthcare system – one that continues to cost the taxpayer for decades.

Research like that published in the MJA this week is important in highlighting the difficulties GP supervisors and registrars face, and the consequences of not attending to the establishment and maintenance of an effective, best-practice clinical-training environment.

Best practice suggests that things change and improve over time. While improvements have been made, GP supervisor teaching allowances and minimum teaching time has remained relatively static.

The entire system still has a way to go in delivering a responsive best-practice environment for Australia’s future family doctors.

It is worth looking in detail at the MJA study to be clear on what it says. The authors reviewed the 10 most frequently ordered tests (number per 100 encounters) by registrars, by training term.

The study is curious on a couple of fronts.

It concludes that “pathology test ordering by general practice registrars increased significantly during their first two years of clinical practice”, with an “11% increase in ordering for each additional training term” .

However, a simple breakdown of pathology ordering by training term set out in the paper seems to contradict this conclusion.

My own calculations of this information suggest that:

• The number of tests per 100 encounters decreased for all tests from term 1 to term 2 (average -11%, range -5% for CRP to -14% for lipids and glucose).
• The number of tests per 100 encounters increased for all tests from term 2 to term 3 (average 9%, range 3% for Pap smears to 17% for glucose).
• The number of tests per 100 encounters decreased for all tests from term 3 to term 4 (average -24%, range -20% for FBC to -34% for both Pap smears and urine).
• The total number of tests per 100 encounters reduced by an average of 26% (range: 20% for LFTs to 38% for Pap smears) from term 1 to term 4 depending on the test.

Even including a 9% increase from term two to three, there appears to be an overall 26% reduction in the number of tests ordered from term one to term four, not an 11% increase each additional training term.

What the facts of the study do highlight, however, is that the drop off in formal protected teaching time between term two and three of a GP registrar’s training has a significant impact on their test-ordering behaviours.

It also backs up what supervisors have been saying for years: dedicated teaching requires appropriate support and resourcing throughout a registrar’s training, not just for the first year.

The study was based on data collected between 2010 and 2014. Since then, greater emphasis has been placed on this issue.

For instance, we have had the NPS’s Choosing Wisely campaign, which commenced in 2015.

And in recognition of the importance of this issue, GP Supervisors Australia has launched a number of initiatives for supervisors and registrars to specifically address education on rational test ordering.

The study also underlines a number of important ongoing issues with GP training:

• Managing uncertainty in general practice is an essential skill.
• Learning to manage this uncertainty is best gained through experience under the supervision of experienced supervisors, providing positive role modelling and teaching over time that is tailored to registrar needs.
• Unfortunately, we have a training system which currently reduces the role that GP supervisors play in a registrar’s education during the four terms.

We acknowledge the vast amount of money that the Federal Government has put into GP registrar training over decades and we are not asking that more dollars be found.

However, we believe it needs to be recognised that direct GP supervision is a safe and cost-effective way of training the next generation of young doctors.

More supervision and support for supervisors is what will deliver an even more efficient health care system into the future.