A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002)
Description
This study sought to examine the utilisation of pathology tests in general practice when investigating tiredness. The clinical records selected for the project encompassed a seven-year time frame from 1 April 1994 to 25 April 2001. The sample was randomly sorted and 345 patients were validated.
to examine the utilisation of pathology tests in the investigation of tiredness in general practice.
Objectives
to demonstrate the indications of pathology in the investigation of tiredness in general practice
to identify and follow a sample of patients with tiredness and review the management processes at these encounters
to assess patient health outcomes
to develop and pilot computer-based guidelines for general practitioners (GPs) investigating tiredness.
The aim and most objectives were achieved by this project. The final objective was partially met, with the study providing information that will enable progress to be made in the area of decision support.
Findings
Significantly more females than males visit the GP with tiredness.
Older patients (>44 years) compared to younger patients (<44 years) visit the GP more than once with tiredness.
There was a mean number of 3.12 tests requested per patient.
The most common tests ordered by GPs were:
full blood count examination (27%)
urea, electrolytes and creatinine (18%)
thyroid function tests (11.8%)
liver function test (10.8%)
tests for diabetes (9.2%)
erythrocyte sedimentation rate (8.7%).
Tests less commonly requested were:
iron studies (7%)
folate tests (3%).
More females (56%) than males (46%) had at least one pathology test ordered, with older patients having significantly more pathology tests ordered.
14% of pathology tests were returned abnormal, and only 3% of these patients had a significant outcome based on an abnormal pathology test result.
Patients with a history of depression were significantly more likely to be tired after six months compared to a patient without a history of depression.
As age increases, the likelihood of having a pathology test increases.
As the number of visits increases then the probability of having a pathology tests also increases.
As age increases, the probability of having an abnormal pathology result increases.
As ‘no problem’ changes to ‘physical’ there is an increased chance of an abnormal result, and changes from physical to psychosocial also increases the chance of an abnormal result.
Tiredness lasting greater than four to six months is more frequently associated with psychological conditions.
Recommendations
A complete blood picture, and possible fasting blood sugar level, may be the appropriate and only initial pathology required to investigate tiredness.
GPs should always conduct a clinical review to determine if there is evidence of depression or other psychological condition, review the patient’s life circumstances to decide whether stresses in work, home or relationships could be a factor, and a physical examination to determine if laboratory tests are necessary.
A pilot decision support study utilising the findings of this study has significant potential to move GPs to more appropriate pathology ordering and better patient management.
Key Project Learnings
The evidence for pathology tests confirming a diagnosis related to tiredness is limited.
Evidence-based guidelines for investigating adult patients with fatigue of less than six months duration were developed in Ontario.
Develop a framework for decision support for GPs investigating tiredness in general practice based on elements identified in the study.
Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)
Description
This project investigated laboratory medicine (pathology) teaching practice and curriculum in undergraduate training institutions (universities and teaching hospitals) across Australia.
to determine what is currently being taught in regard to laboratory medicine in the medical curriculum
to identify:
if curricula content complies with current evidence and best practice
if curricula address the patterns and/or prevalence of clinical presentations that occur within various practice environments
what, where and if applicable, why gaps or inconsistencies are occurring in the current teaching of laboratory medicine
any barriers to the effective teaching of laboratory medicine
incidences where laboratory medicine teaching programs are currently working well
to ascertain who is teaching laboratory medicine
to ascertain the overseas experience in teaching laboratory medicine to medical students
to provide recommendations to the Australian Government Department of Health and Ageing (DoHA) on ways to improve the teaching of laboratory medicine to enable medical students to develop better pathology ordering and interpreting skills to assist in managing their patients.
These aims and objectives were achieved by the project.
Findings
Pathology and laboratory medicine is introduced in the first year of primarily Problem Based Learning (PBL) courses, and in the middle of more traditionally structured courses.
The number of contact hours for pathology and laboratory medicine is estimated at between 250 and 300 across all curricula.
Ethics and medico-legal issues are incorporated into all curricula.
The value of ordering tests for population screening is covered in all curricula.
The basic knowledge underpinning laboratory medicine is largely taught through lectures, tutorials and practicals.
The role of laboratory sessions is declining across all medical schools.
All curricula provide for students to gain experience in the use of basic point of care tests and collection of specimens during clinical rotations.
Computers are used extensively in medical curricula with schools developing a wide range of resources to support student learning.
There is a strong emphasis on developing clinical reasoning in the new curricula.
The focus of teaching laboratory medicine is increasingly on disease presentation.
There were limited cases where the financial aspects of testing were considered.
A range of texts were used.
There was some variation in the involvement of pathologists in teaching with anatomical pathologists the most represented in academic departments.
Clinicians are extensively involved in teaching students in their clinical rotations.
A number of issues related to barriers and opportunities for improved teaching of laboratory medicine to undergraduates were identified.
Service demands in public laboratories and hospitals were noted as a barrier to greater pathologist involvement in teaching roles.
There is a danger that good habits learned in undergraduate programs can be unlearned shortly after graduation as graduates undertake training within clinical teams in public hospitals.
If current teaching of laboratory medicine in Australia is to effectively prepare students to use pathology tests appropriately in their future practice, the literature suggests that teaching approaches should:
provide a firm grounding in basic biomedical sciences and pathology in the early part of the curriculum
develop an understanding of the link between pathology and clinical presentation
facilitate the development of sound clinical reasoning
provide students with an understanding of the application of pathology tests as a component of teaching at the beginning of their clinical training.
Recommendations
Create a fractional, temporary position in each medical school to provide support and assistance in various areas, and evaluate the impact of such positions after about two years.
Commission a study to identify issues or situations that present difficulties for students and recent graduates in appropriately ordering and interpreting pathology tests and present them to a workshop.
Commission an analysis of laboratory medicine education in postgraduate years one and two.
Circulate the core curriculum developed by the heads of academic pathology departments, in collaboration with the Royal College of Pathologists of Australasia (RCPA), to medical schools as a guide for future development of curricula.
Develop a version of the Manual of Use and Interpretation of Pathology Tests that be can stored and accessed on hand held systems such as Palm®, and an abridged pocket version of this Manual be developed covering tests that are likely to be used on a regular basis.
Provide students with more opportunity to visit working laboratories to improve their understanding of the process by which specimens are managed and on how reports are prepared.
Specifically targeted teaching focusing on areas which undergraduate students and recent graduates find difficult would be beneficial.
Support clinical teachers to model good practice in the use and interpretation of pathology tests to improve test ordering and interpretation practices among students.
Expand the range of clinical environments in which students receive their education, training and experience to enable them to develop skills appropriate for managing the chronic and sub acute conditions they will encounter in their professional practice in the community.
Follow on Initiatives and Projects
Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) on page116.
Areas for Future Consideration
Focus on improving the education of medical students in undergraduate training institutions (universities and teaching hospitals) across Australia in laboratory medicine as per the above recommendations.
