Difficult-to-Treat-Depression—Perceptions of GPs and GP Trainees

Introduction: GPs are often the first contact point for mental health concerns. Training to qualify as a GP involves completing a three-to-four year program. Among other things, the training program may include a six-hour mental health training workshop. The study’s purpose was to compare GPs’ and Trainees’ perceptions of difficult-to-treat-depression (DTTD). Methods: Using a semi-structured interview schedule comprising six questions, 10 GPs and six Trainees participated in focus groups or telephone interview. To understand participants’ perspectives, data were analyzed using the Framework Method. Findings: Trainees were less clear than GPs about the meaning of DTTD and other diagnostic terms. GPs’ diagnosis included querying diagnosis and treatment options. Trainees’ experience was limited but they raised barriers including non-response to various treatment trials. Both groups identified management difficulties including: doctor shopping, suicide risk, patients not being well informed;with management difficulties exacerbated by limited access/referring to health professionals, cost and/or unavailability of bulk billing. While some GPs and Trainees had heard of an illness management model or chronic illness model, few used a model. Most reported limited referring to psychiatrists, mainly because of cost and/or limited availability. GPs were more likely to refer to other health professionals and use pharmacological and complementary therapies. Both groups discussed the impact of external factors including cultural factors, patient compliance, treatment failure, and the importance of the relationship between the patient and the professional. Trainees were more likely to stress the importance local clinical guidelines. Discussion and Conclusion: Despite the small size and limited nature, this research provides insight into some of the similarities and differences of GPs’ and Trainees’ experiences and understanding of DTTD. This may have implications for training providers, clinical supervisors and Trainees, and suggests that enhancement in the role of mental health training may be relevant.

Absolute cardiovascular risk assessment by Australian early-career general practitioners: a cross-sectional study

Objective To determine the prevalence and associations of general practice registrars’performing absolute cardio-vascular risk(ACVR)assessment(ACVRa).Design A cross-sectional study employing data(2017–2018)from the Registrar Clinical Encounters in Training project,an ongoing inception cohort study of Australian GP registrars.The outcome measure was whether an ACVRa was performed.Analyses employed univariable and multivariable regression.Analysis was conducted for all patient problems/diagnoses,then for an‘at-risk’population(specific problems/diagnoses for which ACVRa is indicated).Setting Three GP regional training organisations(RTOs)across three Australian states.Participants GP registrars training within participating RTOs.Results 1003 registrars(response rate 96.8%)recorded details of 69105 problems either with Aboriginal and/or Torres Strait patients aged 35 years and older or with non-Indigenous patients aged 45 years and older.Of these problems/diagnoses,1721(2.5%(95%CI 2.4%to 2.6%))involved an ACVRa.An ACVRa was‘plausibly indicated’in 10384 problems/diagnoses.Of these,1228(11.8%(95%CI 11.2%to 12.4%))involved ACVRa.For‘all problems/diagnoses’,on multivariable analysis female gender was associated with reduced odds of ACVRa(OR 0.61(95%CI 0.54 to 0.68)).There was some evidence for Aboriginal and/or Torres Strait Islander people being more likely to receive ACVRa(OR 1.40(95%CI 0.94 to 2.08),p=0.10).There were associations with variables related to continuity of care,with reduced odds of ACVRa:if the patient was new to the registrar(OR 0.65(95%CI 0.57 to 0.75)),new to the practice(OR 0.24(95%CI 0.15 to 0.38))or the problem was new(OR 0.68(95%CI 0.59 to 0.78));and increased odds if personal follow-up was organised(OR 1.43(95%CI 1.24 to 1.66)).For‘ACVRa indicated’problems/diagnoses,findings were similar to those for‘all problems/diagnoses’.Association with Aboriginal and/or Torres Strait Islander status,however,was significant at p<0.05(OR 1.60(95%CI 1.04 to 2.46))and association with female gender was attenuated(OR 0.88(95%CI 0.77 to 1.01)).Conclusion Continuity of care is associated with registrars assessing ACVR,reinforcing the importance of care continuity in general practice.Registrars’assessment of an individual patient’s ACVR is targeted to patients with individual risk factors,but this may entail ACVRa underutilisation in female patients and younger age groups.

Specificity of early-career general practitioners’problem formulations in patients presenting with dizziness:a cross-sectional analysis

Objectives Dizziness is a common and challenging clinical presentation in general practice.Failure to determine specific aetiologies can lead to significant morbidity and mortality.We aimed to establish frequency and associations of general practitioner(GP)trainees’(registrars’)specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.Design A cross-sectional analysis of Registrar Clinical Encounters in Training(ReCEnT)cohort study data between 2010 and 2018.ReCEnT is an ongoing,prospective cohort study of registrars in general practice training in Australia.Data collection occurs once every 6 months midtraining term(for three terms)and entails recording details of 60 consecutive clinical consultations on hardcopy case report forms.The outcome factor was whether dizziness-related or vertigo-related presentations resulted in a specific vertigo provisional diagnosis versus a non-specific symptomatic problem formulation.Associations with patient,practice,registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.Setting Australian general practice training programme.The training is regionalised and delivered by regional training providers(RTPs)(2010-2015)and regional training organisations(RTOs)(2016-2018)across Australia(from five states and one territory).Participants All general practice registrars enrolled with participating RTPs or RTOs undertaking GP training terms.Results 2333 registrars(96%response rate)recorded 1734 new problems related to dizziness or vertigo.Of these,546(31.5%)involved a specific vertigo diagnosis and 1188(68.5%)a non-specific symptom diagnosis.Variables associated with a non-specific symptom diagnosis on multivariable analysis were lower socioeconomic status of the practice location(OR 0.94 for each decile of disadvantage,95%CIs 0.90 to 0.98)and longer consultation duration(OR 1.02,95%CIs 1.00 to 1.04).A specific vertigo diagnosis was associated with performing a procedure(OR 0.52,95%CIs 0.27 to 1.00),with some evidence for seeking information from a supervisor being associated with a non-specific symptom diagnosis(OR 1.39,95%CIs 0.92 to 2.09;p=0.12).Conclusions Australian GP registrars see dizzy patients as frequently as established GPs.The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in vertigo/dizziness presentations.Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars’diagnostic processes is indicated.