New study shows high parental confidence in GPs, but researchers draw bizarre conclusions

High confidence in GPs

A new national study published in the Journal of Paediatrics and Child Health shows that around ninety percent of parents are mostly or completely confident in GPs to provide general care to their children.

This is of course good news.

The findings also show that 93% of the parents participating in the study reported that they would take their child to see a GP in the event of a minor illness, instead of visiting the emergency department – which is exactly what everyone wants.

Therefore I was surprised to read the conclusion from the authors, a group of mainly academic paediatric researchers, that “confidence with GPs is an issue for parents of many walks of life” which could potentially lead to “greater numbers of ED presentations for children with lower urgency conditions.”

Sorry? The results of the study clearly show that only 2% of parents were not very confident in their GP (see table). I wonder what is going on here.

Most parents are confident in their GP. Only 2% of respondents was not very confident. Source: Journal of Paediatrics and Child Health.

 

The authors conveniently omitted the ‘mostly confident’ category (45%) and only reported the ‘completely confident’ category (44%) as their main result, stating that “fewer than half of parents were completely confident” in a GP.

I wonder how many consumer satisfaction studies show a 100% score all the time… The bottom line is that many people inherently have fears when it comes to their own health and especially the health of their children. This may be reflected in their attitudes in confidence of health care services, but this is often a natural fear and as a profession we need to support our patients and address their fears and concerns.

More bizarre conclusions

It appears the authors have a different agenda, as they went on: “Given that GPs in training are having limited experience in child health and that GPs are seeing fewer children overall, more intensive training pathways for paediatric care may be beneficial. One option would be for additional training similar to the certificate for GP provision of antenatal care.”

Additional training? Current GP training already includes childhood conditions as this is core general practice business. GP waiting rooms are full of children and most childhood conditions and preventive health are managed successfully by GPs.

We know that Australia has one of the highest life expectancies in the world, partly because Australian general practice is accessible and offers longitudinal care.

The findings of the study also confirm that parental confidence is greater for those with a regular GP, so instead of providing advice about more intensive training pathways, it would have been useful if the authors had recommended that parents find a regular family GP they trust.

Seeing a GP who is a RACGP Fellow (Royal Australian College of General Practitioners) should serve as reassurance to parents that they are seeing a specialist GP who has trained at the highest possible general practice standard in Australia – including child health and antenatal care.

There are of course challenges with doctors coming into GP training in this area. In recent years, the access of junior hospital doctors to paediatric experience in hospitals before entering GP training has decreased. Like all training and learning needs, this is taken into account when supervising GP trainees to ensure patient safety.

National study of parental confidence in general practitioners

It would have been useful if the authors had recommended that parents find a regular family GP they trust. Source: Journal of Paediatrics and Child Health.

Not helpful

If there is some area we need to do better, we need to know that but based on the findings of this study I don’t see a major problem with the paediatric care provided by Australian GPs.

My take-home message from this study is first of all that this style of reporting research findings is, at best, not helpful.

Secondly, the study clearly demonstrates the need for quality research in general practice, in terms of improving access to high value treatments and the appropriate use of limited health resources.

30 thoughts on “New study shows high parental confidence in GPs, but researchers draw bizarre conclusions

  1. Hi Edwin – thanks for delving into the stats on this paper, and I completely agree with you. The paper did not draw an accurate conclusion from the data.
    I note that none of the authors seem to be from general practice. I would really like to see more engagement of GPs in research about general practice. We would never accept research in any other field that did not involve stakeholders in the design, collection, and analysis of data. I don’t understand why stakeholder engagement, i.e. GPs, is not seen as essential for research about general practice.
    Supporting GPs to have an interest and skills in research is an ongoing need. It is great to see RACGP support for GP-engaged research.
    Thanks again for drawing attention to this – maybe you could write a response to the article in the journal?

    Liked by 2 people

  2. I agree with almost everything in your article. Therefore, less than 51% of commenters completely agree with you.

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  3. Surely the biggest blunder is to equate “confidence” with “assessment of competence”. Being “mostly confident” can’t mean much more than “I don’t know everything about the doc’s range of skills”; it can’t be taken – certainly can’t be taken automatically, logically – to mean “I do know exhaustively about doc’s competence and I assess it as wanting”. Why it matters? Because the emphasis should probably be upon patient education and information, not upon GP training!

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  4. I reckon I’m completely confident in what I’m doing as a GP about 44% of the time and mostly confident another 45%. About 2% of the time I have NFI – and I refer those patients to someone who might!

    Liked by 2 people

  5. I would be scared of willingness to sacrifice all responsibilities to a medical practitioner because of 100% confidence.
    I think if a patient has around say 78.5% confidence in a my skills, it would mean there would be questions asked which may well improve care.

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  6. I read with interest your comments on the article published recently on parental confidence in GP care for children. This was the latest in a series of studies on both GP care of children and the training of GP registrars in the care of children, most of which were referenced in this article.

    These studies (selected references below) have used patient surveys, GP surveys, Medicare data, BEACH data and RECENT data to take a comprehensive look at the issue of paediatric care by GPs. All of these studies have been conducted with either GP practitioners or GP regional training leaders as co-investigators and co-authors.

    I believe that GPs are the backbone of the Australian health care system and must be supported to be able to provide the best care possible for children and to earn the confidence of parents. They are being asked to do more and more for increasingly varied and complex patients. The challenge ahead requires putting energy toward solutions and using evidence and data, not anecdote or opinion, to move forward in a constructive fashion. Only through the use of data can we move past our own anecdotal experiences and begin to examine the trends within the health system.

    The findings of these studies include:

    Over the past 2 decades there has been a significant decrease in the proportion of GP patient visits that are for children, despite an overall increase of 13% of the paediatric population in Australia.
    There has been a marked decrease in both the proportion and absolute numbers of GP extended consultations for children, despite the fact that there are more children alive with chronic illness than ever before
    The age band with the greatest number of ED presentations (by almost 50%) are children 0-4 years of age. This is for lower urgency conditions as well as higher urgency conditions.
    90% of all lower-urgency conditions for children 0-4 years of age presenting to the ED meet criteria for a “primary-care type” visit
    Of over 1000 parents studied who presented to 4 different hospitals in Victoria for lower urgency conditions, fewer than half saw a GP prior to presentation and most of those were actually sent by their GP (for lower urgency conditions).
    Over 2/3 of parents felt that all injuries, even minor sprains and strains, should not be seen by a GP.
    There are lower numbers of children seen by GP registrars than for other age groups. Further, most GP registrars do not see even 1 extended consultation for a child during their apprenticeship
    GP registrars refer children to specialty care at rates much higher than they do adults.
    There are no requirements for the number of children that a registrar must see in their apprenticeship portion of their training.

    If you have further questions, after reading the data on the issue, I would be happy to speak with you. We must find constructive solutions to these issues, but the first step is becoming familiar with the existing data.

    Warm regards,

    Gary L. Freed

    Harriet Hiscock, Gary Freed, Simon Morgan, Amanda Tapley, Elizabeth
    Holliday, Andrew Davey, Jean Ball, Mieke van Driel, Neil Spike, Lawrie McArthur & Parker Magin
    (2017): Clinical encounters of Australian general practice registrars with paediatric patients,
    Education for Primary Care, DOI: 10.1080/14739879.2016.1266697 http://dx.doi.org/10.1080/14739879.2016.1266697
    Freed GL, Sewell J, Spike N, Brooks P, Moran L. Changes in the
    demography of Australia and therefore general practice patient populations.
    Aust. Fam. Physician 2012; 41: 715–9.
    Freed GL, Spike NA, Sewell JR et al. Changes in longer consultations for
    children in general practice. J. Paediatr. Child Health 2013; 49: 325–9.
    FreedGL, Gafforini S, CarsonN. Age
    distribution of emergency department
    presentations in Victoria. Emerg.
    Med. Australas. 2015; 27: 102–7.
    Freed GL, Spike N, Magin PJ,
    Morgan S, Fitzgerald M, Brooks P.
    The paediatric clinical experiences of
    general practice registrars. Aust. Fam.
    Phys. 2012; 41: 529–33.
    Sarah GAFFORINI, Erin TURBITT and Gary L FREED. Lower urgency paediatric injuries: Parent preferences for
    emergency department or general practitioner care. Emergency Medicine Australasia (2016) 28, 564–568
    Gary L FREED,1 Amy R ALLEN,1 Erin TURBITT,1 Caroline NICOLAS1 and Ed OAKLEY2 Parent perspectives and reasons for lower urgency
    paediatric presentations to emergency departments. Emergency Medicine Australasia (2016) 28, 211–215
    Freed GL, Bingham A, Allen AR,
    Freed MA, Sanci L, Spike N. Actual
    availability of general practice appointments
    for mildly ill children.
    Med. J. Aust. 2015; 203: 145.
    Freed GL, Spike NA, Sewell JR et al.
    Changes in longer consultations for
    children in general practice. J. Paediatr.
    Child Health 2013; 49: 325–9.
    Turbit E, Freed GL Paediatric emergency department referrals from primary care. Australian Health Review http://dx.doi.org/10.1071/AH15211
    Gary L Freed, Simon Morgan, Amanda Tapley, Neil Spike, Parker Magin. Referral rates of general practice
    registrars for behavioural or mental
    health conditions in children AFP VOL.45, NO.3, MARCH 2016
    Freed GL, Turbitt E, Marina K, Gafforini S, Sanci L, Spike N. General Practitioner Perspectives on Referrals to Paediatric Public Specialty Clinics. Aust. Fam Physician. (In Press)
    Freed GL, Turbitt E, Kunin M, Garrofini S, Sanci L, Spike N. Children referred for specialty care: Parental perspectives and preferences on referral, follow-up and primary care. J Paediatr Child Health. 2017 Jan; 53(1):18-25.
    Freed GL, Turbitt E, Gafforini S, Kunin M. Paediatrician Perceptions of Patient Referral and Discharge. Aust. Health Review, (Epub ahead of print): September, 26 2016.

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    • Thanks Gary, would appreciate to hear why the data have been presented in the way they have. It has been perceived by many GPs as slightly misleading and unnecessary hurtful. I believe that would be a first step. Thank you.

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      • Thanks for your note. The study of parental confidence was not the first, nor only study examining the issue of GP care for children. There are real and substantive trends occurring now with regard to GP training and care regarding children. I think the GP community needs to consider all of the available data and decide what can be done to address these issues. The truth is that many parents in Australia are not only expressing their opinions, but also changing their patterns of care. They are bypassing their GP more frequently, being referred to the ED by their GP more frequently and are being referred for specialty care at much higher rates. The problems with GP training in the care of children appear not to be taken seriously, despite the evidence that exists that the problem is getting worse.

        Although I understand the defensive nature of the response, I think it would be more productive to actually begin to address the underlying issues.I believe GPs want to provide the best care possible for all Australians. The current focus on adults and the elderly is important, but cannot be done at the expense of excellence in care to children.

        Just out of curiosity, were you aware of all of the literature published on this in the last 3-4 years that provides objective data on these issues? If not, is there a way to bring this information to the GP community in a productive manner? Perhaps you could write a review of the data on this topic for your blog as a start?

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        • It would have been nice to have had this conversation before the article was published and media attention sought by your team. As I said it is now essential to hear why the data have been presented in the way they have. E.g. why omit the ‘mostly confident’ category (45%) and only report the ‘completely confident’ category (44%) as the main result? The conclusions of the article have been perceived by many GPs as slightly misleading and unnecessary hurtful.

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  7. Unfortunately Gary the conclusions drawn based on the data in the article you referenced were picked up by prime time media (Sunrise, The Project) and in my opinion have done irreputable harm to public opinion about General Practice.

    I think being ‘mostly competent’ with my GP is a good thing. We all need a healthy dose of scepticism to ensure we are not blindly following advice without question.

    Only 2% of parents said they were not very confident. 89% completely confident or mostly confident is a great result for GPs. Perhaps this should open up further qualitative research into ED attendance and reasons for the other data you presented.

    GP morale in the current political climate is low. It is very disappointing to read articles with conclusions such as yours in what I perceive to be overwhelmingly positive data about confidence in GP.

    Let’s work together, not against each other

    Liked by 1 person

  8. I appreciate the sentiments expressed and understand the concern. However, the data were presented as the parents expressed. We were very clear in defining what was meant by completely confident and mostly confident in both the survey and the paper—-I cannot speak to the news reports. For those who have not had the chance to read the paper and see the definitions, here is how it was presented to parents:

    Completely confident: “can handle almost all general health issues for my child”
    Mostly confident: “can handle most general health issues for my child”

    Importantly, the questions only asked about “general care”, not specialty care or chronic conditions. As such, we thought it would be a reasonable expectation that GPs should have the confidence of parents to handle “almost all” (Not All, but almost all) general health issues. If parents felt that GPs could handle “most” general issues, we hypothesized (and were clear in the paper that this was a hypothesis) that meant there were general issues (not specialty issues) for which they would be more likely to go to the ED or request a referral. This hypothesis was based on our other published studies of over 1000 parents presenting to EDs with their children who had lower-urgency conditions. Many of these parents had either not gone to see their GP (during office hours) or were sent by their GP to the ED for these lower urgency conditions. This study is one of the ones referenced above.

    I would also like to point out that all of the other studies on this issue (many of which I listed above) were also published and picked by the media. Although I understand this study was more personal to many GPs, I hope this provides an opportunity for the GP community to take a closer look at all of the data published on this issue and begin to address these worrisome concerns regarding the care of children. If GPs can get ahead of the problem they can and should be the leaders in figuring out how to fix it. I believe GPs are the best people in the Australian health care system to provide primary care—they just need the training and support to do it now and into the future.

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    • Thanks for answering some of our questions on this blog Gary.
      I have a question about your method – has the survey that you used been validated? Specifically for the meaning that is given to the survey questions by the respondent.
      Thanks for your engagement

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      • Thanks for your question. Yes. The survey was validated both through cognitive interviews/pretests with pilot respondents and also through face validity with practicing GPs.

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        • Thanks Gary – can I ask why this wasn’t specified in the methods of this paper? It seems to be a very important methodological issue when a lot of emphasis is being placed on the meaning of the responses.

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    • Thanks for taking the time to respond. The meaning & interpretation of ‘almost all’ and ‘most’ may differ from person to person and that’s one of the reasons why this study may not convince everyone. If however there are concerns about the care for children in general practice we will need to look at it and we may need to do our own analysis of the available evidence. Once again thanks for commenting.

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      • Thanks so much for your reply. I would welcome a review of the data from all of the existing studies in your blog. I know it is read by many GPs and may help to start a constructive engagement on the issue.

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    • Thanks for you reply Gary. As I stated before, there is a difference between completely confident and mostly confident, but both are positive answers. The criticism here is not about the other studies that you mention it is about the summation of the authors that 45% of mostly confident is a negative answer.

      I am sorry if this sounds inflammatory but I think that your hypothesis is incorrect and fails to take into account a holistic approach to the decision making of parents.

      I wonder why, for example there was no mention of access or cost?

      I would argue that many parents would give similar responses about any of our profession including paediatricians and this is a normal response for healthy skepticism.

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      • Thanks for your note. Several of our other studies address access and cost of GP care. Those previously published studies are listed above in my first comment.

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        • Thank you Gary but as these are published in Emergency Medicine and Paediatric Journals I can not access them to review the data.

          You have not yet commented on why you or your researchers concluded that ‘mostly confident’ is a negative answer?

          Liked by 1 person

          • From one of my above comments:

            These were the definitions used in the survey:

            Completely confident: “can handle almost all general health issues for my child”
            Mostly confident: “can handle most general health issues for my child”

            Importantly, the questions only asked about “general care”, not specialty care or chronic conditions. As such, we thought it would be a reasonable expectation that GPs should have the confidence of parents to handle “almost all” (Not All, but almost all) general health issues. If parents felt that GPs could handle “most” general issues, we hypothesized (and were clear in the paper that this was a hypothesis) that meant there were general issues (not specialty issues) for which they would be more likely to go to the ED or request a referral. This hypothesis was based on our other published studies of over 1000 parents presenting to EDs with their children who had lower-urgency conditions. Many of these parents had either not gone to see their GP (during office hours) or were sent by their GP to the ED for these lower urgency conditions. This study is one of the ones referenced above.

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  9. Yes the 2 categories (‘mostly’ & ‘completely’ confident) should have been combined.

    This clearly shows that almost ninety percent of parents are mostly or completely confident in GPs to provide general care to their children.

    Sadly academic research seems to be serving political and other agendas these days which makes it hard to trust some of the evidence.

    If this is the way this research team presents data and draws conclusions, their previous and yet to be published work should be looked at very carefully.

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    • I think we will agree to disagree on this. Combining would eliminate the differences parents expressed, no matter how uncomfortable that makes people feel. I believe we should seek more input from our patients and parents, even when it is not what we want to hear. I strongly encourage you to look carefully at the other published work by our team (again, which includes practicing GPs and those involved in GP education) (as you suggest) and place the results of this study in the context of the concerning data on trends in GP care for children. To simply ignore those trends and think all is well if we “just combine categories” may make GPs feel better but will not allow them to take ownership of the issues and work to define solutions. I fear if GPs do not have the courage to grapple with the data, and show initiative in developing solutions for real problems, others will do it for them. Personally, I think it would be best if the GPs stepped up to the plate and took on the problems in primary paediatric care and training in a meaningful way.

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      • This is not about listening to our patients – which is of course important and always the right thing to do, but it is distracting from the real issue here. It’s also not about ‘defensive’ or ’emotional’ responses from GPs, nor is it not about GPs not willing to ‘take ownership and work to define solutions’. I’m sure you know that most GPs care about their patients and quality care, just like most paediatricians do.

        The real issue here is about how a research team interprets and presents data and the biases at work. Gary we need robust, honest and genuine information before we change what we do. Clearly there is a difference of opinion here and I’m happy to agree to disagree as you suggest, but if you really want to change things and make sure the general practice community can accept your work, you have to come up with different material.

        If you are unable to acknowledge this and take the message on board I’m afraid your work will be ignored by many. On the other hand, if you are able to move away from political agendas and other biases and work more closely with general practice you may be surprised what can be achieved.

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        • I appreciate your sentiments. I have no political agenda. My only agenda is to improve the primary care for children in Australia. Hopefully we are both on the same side of this issue. I encourage you to look at all of the other studies I have identified above. The data speak for themselves. As I have mentioned, I work closely with many in general practice. If you and others want to make a difference in the care provided to children, please take a closer look at those studies. I think the real issue here is paediatric primary care, no matter how categories are combined or not. If you do not like how we presented the results of this parent survey, for whatever reason, I respect that. However, I sincerely hope that does not result in you and others ignoring the underlying issue of worrisome changes in paediatric care and education among GPs. I challenge you and others to be as focused on those data as you have on this parent survey.

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          • As I said if there are concerns about the care for children in general practice we will need to look at it and we may need to do our own analysis of the available evidence.

            At the same time the ‘worrisome’ changes you speak of seem to be contradicted by the results of this study which clearly show that almost ninety percent of parents are mostly or completely confident in GPs to provide general care to their children.

            Once again thanks for taking the time to comment here and to respond to the questions and concerns. I believe everyone has had a chance to say what needs to be said and to avoid arguments being repeated I will now close the comments on this post.

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  10. Pingback: Bizarre research article about parental confidence in GPs gets a mention in ABC’s Media Watch | Doctor's bag

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