General practice education is not the universal solution

Melinda Choy

17/05/2019 2:38:56 PM

GP and researcher Dr Melinda Choy questions whether reliance on general practice education is effective – or drowned out.

Dr Melinda Choy
Is general practice education always the answer? ANU researcher Dr Melinda Choy says maybe not.

Everyone wants to educate GPs. There is a pile of advertisements in my practice lunchroom from the local primary healthcare network, the RACGP, local hospitals, specialists and of course, the drug companies. Pinging into my email inbox are hundreds – even thousands – of modules, webinars and e-audits that I can do to improve my practice.
While I do, of course, want to continually update my practice and I am committed to the principle in medicine of lifelong learning, sometimes I wonder whether all the researchers, advocacy groups, companies and people who want to educate us realise that they are all trying to do it at once. It’s a crowded market.
I get where they are coming from. There are many significant public health issues requiring a coordinated approach. GPs are at the coalface of patient care, and there are many of us. If you scale up a general practice education initiative, it stands to reason you could help a large number of patients.
So I can understand why it is easy to recommend education as a policy. But I have to ask – should it really be the default go-to solution for every public health issue?
I’ve come across several recent examples that make me think – perhaps not.
Take the recent announcement by Health Minister Greg Hunt to pledge $6.8 million to the better understanding and management of chronic pain, following the release of The cost of pain in australia, a report by Deloitte Access Economics and funded by Painaustralia, a consumer advocacy group. It is good news and helps tackle an important health issue in Australia. Most of the funding will go towards improving access to pain management services for rural Australians, and some will go towards improving consumer and public awareness and education.
That’s fine.
But what I question is the $1 million allocated for a nationwide general practice education program to enable GPs ‘to participate more effectively in pain management care’.
The premise of this recommendation in the Deloitte report starts with three trials of varying quality, a few of which showed an improvement in line with best practice pain management, but no overall decrease in opioid prescribing volume.
Then, US Centre of Disease Control (CDC) data showing a drop in opioid deaths with a drop in opioid prescriptions was extrapolated to say that Australian opioid-related deaths could potentially be reduced with a general practice education program.
Essentially, the recommendation that a general practice education program to reduce opioid-related costs and harms, including overdose-related deaths, is based more on hypothetical calculations and assumptions rather than high quality trial evidence.
So will this really work the way it is promised to work? The evidence is distinctly mixed on whether general practice education interventions are effective in changing patient outcomes.
For instance, a systematic review and meta-analysis of whether general practice training in depression care affects outcomes, published in 2012, looked at 11 studies and found that provider training on its own did not seem to improve depression care.
Further, a 2014 systematic review published by Australian Family Physician into online continuing medical education (CME) for GPs found there was little evidence for the impact of CME on patient outcomes.
By contrast, an Implementation Science overview of reviews published in 2017 suggested some benefit for patient outcomes from physician education interventions.
So what can we conclude? There is some evidence that carefully controlled trials of general practice education interventions can change some patient outcomes. But that does not necessarily equal an effective go-to policy in the real world.
Rather than relying on medical education as the panacea, I think we need to think more broadly about effective measures for change.
I feel that many producers of educational interventions – whether economists, researchers, public health campaigners, advocacy groups or the government – need to recognise the context that their education interventions are going into.
Education – which by its nature has to be broad – can be rendered useless if we do not understand the context.
Put simply, efforts to educate my patient who has been smoking for 20 years about the risks and benefits of smoking while she is in the middle of a crisis at work will fail.
Does the specialist who wants GPs to better manage their one condition of interest know that his education intervention is yet another colourful flyer in the tea-room and his seminar is at the end of another long day?
I wonder if he realises that we see many patients, each with their own interacting conditions. His view of how to treat his isolated condition of interest might not apply as universally to each of them as he imagines. General practice is valuable because we care for whole people in all their complexity.
Though we may not provide as high quality care for a specific disease than specialists, general practice and primary care are associated with better health and value for both the individual patient and population. Does the specialist understand that I am actually caring well for the patient with his condition of interest, even if I am not technically treating the condition perfectly according to guidelines?
But if the government really does think that general practice education interventions are one of the best ways we can save and improve lives, why not subsidise two working hours a week for every GP to be educated, instead of leaving it up to us to claw out time from our personal lives? Many hospital-based specialists are allocated annual funding for professional education.
Or perhaps we can think more broadly and creatively about how to create change and improve patient outcomes.
After all, the Nuffield ladder of intervention with eight steps ranks education as only one step above doing nothing, and offers six other categories of higher level interventions to guide and enable better choices. One of these higher categories involves restricting choices, and the upscheduling of codeine is a good example of another way to reduce opioid use without increasing opioid prescriptions.
Other options include environmental and system restructuring – I’m watching the slow development of a consistent national real-time prescription monitoring system, which will improve my ability to make more informed and safer decisions when prescribing high-risk medicines.
We could also look at nudge theory, the behavioural economics approach at the centre of the 2017 Nobel Prize for Economics, which proposes positive reinforcement and indirect suggestions as effective methods to influence people.
Some of these other interventions are more cumbersome to implement than another general practice education module, but if they are proven to be more effective, then surely they are worth it.
Because while general practice education has an important role in our health system – to support GPs in providing high quality whole-person care for our patients – it should not be over-relied upon as a go-to tool for experts to improve public health issues.

continuing professional development general practice education

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Catherine Regan   21/05/2019 6:29:32 AM

Very valid comments, Melinda (and i’m In GP education). Unfortunately government often sees delegating education to someone else as a cheap and easy way to be seen as doing something and increasingly evidence based public health is criticised as “nanny state”.

Anne Balcomb   21/05/2019 8:33:06 AM

Thanks Melinda for this article.
Totally agree with the overload of GP educational offers that come from so many directions and that the GP is expected to attend to undertake regularly out of hours before or after a long day. Many are not pitched at the practical day to day level for primary care.
Like your idea of paying all GP’s to attend for a 2 hour universal pain update with the $1 million... and yes staff specialists in hospital settings have large budgets allocated for them to attend regular paid educational conferences and updates .. so there is a great disparity.
Think that the effect of more widespread reforms programs does sound alike better bang for the buck in actually creating change.
Keep up the good work and hope you can influence a few policy makers !

Oliver Frank   21/05/2019 8:44:07 AM

Well said, Melinda. GPs do need 'system restructuring'. As you say, well-meaning people who are not clinically practising GPs don't understand GPs' working environment, and because of this, they continue to advocate education, much of which includes wishful thinking such as: "We want GPs to remember to do X". That does not work. I explained this in MJA Insight:

Casey Parker   21/05/2019 9:29:45 AM

Great article and research
Lots of food to think there

Kirsty Douglas   21/05/2019 10:53:22 AM

Nice commentary Melissa thank you!

Dr Sally Dunbar   21/05/2019 3:28:52 PM

Well said Melissa- there is a massive amount of educational material we seem to be expected to keep up with in our spare time! A recent article I read somewhere said that there was no excuse for GP's to be ignorant of new PreEP prescribing because there was a "free" course. Well it might be free w.r.t. money, but not free of unpaid time commitment.
Regarding pain management, I have attended plenty of lectures on this and all assumed that patients are able to access good multidisciplinary care, as well as suitable exercise options, if only their GP's thought about it! Where I practice this is often only possible for people with W/C or MAIB claims. Cost and transport is prohibitive for most.

Cathy Brooker   21/05/2019 10:46:54 PM

Great article Melissa, hitting to the heart of the complexity of our jobs.
Comedian Dr Ahmed Kazmi addresses many of the issues you mention and talks of a "6 monthly update day".
Imagine if the federal government to provided for well resourced academic GP's to excellently present the most important and valid pieces of new information in a single day that we would be paid to attend M-F during normal hours at no cost. Most other professionals in our society would be surprised to hear this does not happen already.

Regarding your Nuffield ladder, I'm concerned sometimes such interventions make our lives a lot harder. Locally, public hospitals are refusing referrals that do not fit very strict criteria for presentations varying from sleep apnoea, to paediatric in-toeing to adult otitis externa. ACAT and child development referrals must now be done on line, muggins GP's forced to type in all demographic details...etc etc...

Dr Lisa Meriah Fraser   25/05/2019 7:09:27 AM

Great article. New ways of thinking with patient outcomes at the forefront. I want more money for my registrar's education, shared registrar/GP education, practices design their own education using resources to meet their own unique practice needs, and system wide change is ideal. I can't wait til data collection has equal place to research with KPIs in mind. Sure it will be sobering. But i would love to know how many of my practice patients are high cardiovascular risk, and how many had a discussion about exercise and nutrition in the last year. It will be great. Real data. Real time. And for us to action with group/system approaches. Otherwise all of this education is piecemeal and average quality.

Dr Rodney Paul Jones   25/05/2019 11:57:21 AM

Nudge Theory . I'm getting the nudge to prescribe more statins

Dr Sharmila Kumar   26/05/2019 10:59:39 PM

Thank you Melissa for a great article with "food for thought"..Love the idea of paid time for education .. believe it should be compulsory and be linked to our CPD.
Also relieved to know that through AGPT, we teach registrars and hopefully they will apply the EBM triad with best available evidence, p.values and clinical experience.

Dr Srishti Dutta   25/06/2019 3:01:24 PM

Thanks for taking the time to ask a question many of us would have thought of too. Although I agree with you entirely in terms of 'context' being key , education is often used by the bodies you name as an engagement tool, just as much as it is a knowledge /skill improvement tool. I often wonder if it simply legitimises the process of GP engagement , which on its own would not be able to demonstrate its value to a system which relies almost entirely on quantitative data to showcase and improvement. To me the value lies in the conversations not the boxes we tick on an evaluation form and a lot depends on culture change which enables GPs and systems to provide better quality to patients .