Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003)
Description
This project sought to undertake an analysis of current Laboratory Medicine (Pathology) teaching practice in pre-vocation and general practitioner (GP) vocational training.
to provide a comprehensive analysis of how laboratory medicine is currently taught during pre-vocational and vocational GP training
to identify where gaps exist in the current teaching of laboratory medicine in pre-vocational and vocational GP training
to identify options for teaching laboratory medicine more effectively in pre-vocational and vocational GP training.
These aims and objectives were achieved by this project.
Findings
Pre-vocational and Vocational GP Training
The reliance of clinical teaching has meant pre-vocational and vocational training are closely related to the patterns and prevalence of conditions within the practice environment.
The overall approach to pre-vocational training in Australia is comparable to that in other English speaking counties, with an emphasis on ward-based teaching.
The curriculum content for Junior Medical Officers (JMOs) varies considerably within and across jurisdictions, as does the extent to which pathology test ordering is incorporated within the curriculum.
The content of teaching is dependent on the clinical rotation and the views and practices of the consultant, and of the clinical team more generally.
Where financial accountability was the responsibility of clinical units (at least to some extent), the use of pathology was incorporated into ward meetings and feedback provided to JMOs.
The prominence of bedside or ward-based teaching in the curricula for JMOs contributes to a high degree of variation between hospital sites, and between clinical units within a single institution. This increases the importance of the practice of senior clinicians.
Gaps in the Current Teaching of Laboratory Medicine
There is limited involvement of university medical schools in vocational training compared to other English-speaking countries.
The use and interpretation of pathology tests has a limited focus within the training program for GP registrars.
There are different priorities with general practice compared to teaching hospital practice.
The involvement of pathologists in clinical teaching and review of cases is limited, partly due to the limited numbers of pathologists and the demands placed on modern laboratories. There was also minimal global guidance by pathologists regarding overall diagnostic testing strategies.
Most attention is focused on tests JMOs did not order rather than on the tests ordered. The reported lack of consensus among senior clinicians was identified by JMOs as a factor that limited their ability to gain an understanding of appropriate practice.
A JMO is unlikely to question or challenge the practice of a senior colleague in the existing culture in the medical profession which is characterised by autonomy, competitiveness and hierarchy. For example, JMOs order tests that particular consultants always request to avoid the risk of embarrassment during ward rounds. There is also examination and feedback regarding what was ‘not’ ordered, so over ordering is practiced to avoid embarrassment.
JMOs have limited access to or experience in a laboratory, but there is variation across sites with greater access to both pathologists and the laboratory in rural sites.
Barriers to improving how JMOs learn about the ordering and interpretation of pathology tests include:
the lack of incentives for laboratories to reduce ordering
the balance between staff specialists and visiting medical officers
increasing sub-specialisation
the view of the laboratory as a “black box”
changed working hours for JMOs have reduced the range of cases they see and the extent to which they are involved
the shortage of pathologists.
Options For Teaching Laboratory Medicine
Interventions which target only one factor contributing to test ordering are likely to have a limited impact. The linkage between education of JMOs, feedback to consultant staff and building consensus around an accepted evidence base appears to present a comprehensive approach to changing practice.
A key consideration on the validation of knowledge within the medical profession relates to the location of the source within a professional hierarchy.
Personal preferences and knowledge, the environment in which practice occurs and the feedback provided within that environment affects the approach taken to ordering tests by individual medical officers.
Given the reliance on clinical teaching, both prevocational and vocational training are closely related to the patterns and prevalence of conditions within the practice environment.
Where hospitals have introduced protocols for the utilisation of high cost tests, JMOs indicated they were useful in informing them of appropriate practice, and diminishing the risk of finding themselves taking a position that may be in conflict with their consultant.
Interns and residents identified registrars as a major source of information guidance and teaching.
General Findings
There is a high level of contact maintained (usually by telephone) with pathologists in relation to tests ordered and their interpretation.
Registrars typically order considerably less tests when they move from hospital-based practice to community-based general practice.
Patient expectations can influence the decision to order pathology tests.
There are limited incentives to develop more effective approaches to the use of pathology as savings were diverted to other areas of the hospital operation. Initiatives to reduce volume of tests or costs should focus on a whole system approach rather than on a specific unit or sector of a hospital.
environment in which prevocational training occurs
potential conflict of interest for pathologists employed in the private sector
perception of government source information and material
lack of direct costs.
Recommendations
The Australian Government Department of Health and Ageing (DoHA) should consider allocating resources to support the expansion of the Rational Investigation Ordering (RIO) collaborative.
DoHA should convene a working group with representatives of the States and Territories to gain support for a requirement that a component of savings resulting from the RIO collaborative be allocated to support increased involvement of pathologists in the training of JMOs.
A criterion for the support of individual proposals to the RIO collaborative include a project component to emphasise the value and importance of clinical assessment including history taking and physical examination.
Funding should be allocated to support the Royal College of Pathologists of Australasia (RCPA) to develop a Manual for Use and Interpretation of Pathology Tests as a module of current GP practice management systems.
A working group involving Diagnostics and Technology Branch, Royal Australian College of General Practitioners (RACGP) and the RCPA should be established to develop a publicity program raising awareness that ordering pathology tests is not an indicator of the quality of medical care being provided.
The Commonwealth should support the RACGP and RCPA to prepare a pathology audit package for GPs.
The Commonwealth, in seeking to support the broader implementation of the RIO program, negotiates with State and Territory Health Authorities for allocation of a specific proportion of savings generated to provide time for pathologists to be located on wards in major teaching hospitals in all jurisdictions.
Comprehensive approaches to provide opportunities to enhance the learning achieved by JMOs should be developed by:
improving the knowledge base of JMOs through targeted education
providing detailed audit and feedback regarding test ordering practices
developing consensus regarding the appropriate application of pathology.
Opportunities for improving how JMOs learn about the ordering and interpretation of pathology tests include:
the establishment of protocols reflecting consensus regarding appropriate test ordering
the implementation of the RIO program more generally
the application of savings generated through pathology
the increased role of pathologists on the wards
including GP and community rotations in JMO training
utilising computer technology to reduce duplication and inappropriate ordering
increasing the emphasis on good clinical history taking.
Opportunities for improving training learning and practice related to pathology test ordering and interpretation for GPs undergoing vocational include:
a focus on prevocational training
inclusion of the Manual for Use and Interpretation of Pathology Tests on software such as Medical Director
establishment of an independent advisory service
education of patients to modify expectations
development of a national module related to pathology testing
development of a supported Continuing Professional Development (CPD) audit package for GPs
Benefits and Risks of Pathology Testing (Current) on page 152.
Areas for Future Consideration
Instigate global guidance by pathologists regarding overall diagnostic testing strategies, especially for JMOs, in the form of clinical pathways and/or via a consensual approach within clinical teams or units.
Investigate the viability of placing pathologists in hospital wards to mentor JMOs.
Investigate the viability of providing detailed audit and feedback regarding test ordering practices.
Improve the knowledge base of JMOs through targeted education.
