How can we know what we don’t know?

 

I asked an amazingly brilliant GP, who has been one of my long time mentors, why he had had a few patients with a TSH <0.05 for many years. He replied that he titrated to T3/T4 levels as he always does. He was horrified when I showed him that best practice is to titrate to TSH not to T3/T4 and that his patients were possibly at increased health risks. He couldn’t believe it! How could he have been practicing for such a long time and never come across this!! In reality, his patients felt fine, and therefore there was no opportunity for feedback. And this doctor is brilliant! It is SO easy to keep doing what we have always done and not know if it is best practice!

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“Makes you think – what might you be doing in not the best way? And how would you know?”

 

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I remember being told at the first day of medical school that 50% of what we will be taught will be shown to be wrong. How do we know which 50% to forget?!

When we are students and trainees we have someone looking over our shoulder gently nudging our clinical practice towards best practice. When we finish training however, and we are out on our lonesome. How do we know if we lapse into ‘not the best practice’ or when the evidence base shifts away from our usual practice (I wish it would stop doing that!)?

So! I just casually asked 2500 Australian GPs and GP registrars what they wished other doctors knew – or could be better at – on a forum called GPDU (GPs down under – closed group on Facebook). This was open slather – suggestions for patients, students, junior doctors, and all specialist groups. I almost broke Facebook with the MASSIVE response.

So before you have a look at the list I want to give one piece of advice. We are all human, we all make mistakes, we are all learning, and I would rather see the doctor who accepts new practices and adapts/changes/learns.

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Be humble and be better. Don’t be confronted – be excited!

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Disclaimer: I am NOT stating that you should do all of these things. These are all things to make you stop, think, and if you are uncertain, go and look up the evidence yourself. The responsibility you take for your own clinical practice is your own and you treat your own patients.

* Some of these are contentious – but that is part of the fun of medicine. Let’s debate and discuss! I will put up the links to evidence where I can find it.

** I have put in brackets the amount of ‘likes’ they received. Think of it as a guide as to how strongly everyone felt about a particular issue. Not as a guide to whether one thing is more important than another.

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Top 10 “Liked” suggestions which we should change:

1. Sending the “tears and smears” to the nice lady doctor (49) – Aus Doc – Gender in general practice
2. Prescribing duromine for weight loss on every overweight patient (39) – FOAM4GP debate
3. Using urine bags to collect urine specimens (36) – J Paed 2000 – (62% contamination rate!)
4. Prescribing benzodiazepines long term for ‘anxiety’ or ‘insomnia’ (36) – RACGP Benzodiazepines guideline
5. Performing quantitative bHCGs on routine pregnancy bloods (36) – Womens Hospital Shared care Guidelines
6. Suggesting a previous doctor’s management was inadequate without knowing the circumstances (35) – It is not required for patient care. Can provide feedback to the previous doctor if required – Journal of General Internal Medicine 2013, Communication and Courtesy MJA
   
7. Not prescribing a spacer with inhalers (30) – Asthma Handbook
8. Not doing asthma action plans (30) – Asthma Handbook
9. Commencing LABA as first line for asthma (30) – Asthma Handbook
10. Ordering Herpes Simplex Serology (30) – I’m still trying to brainstorm a time when this would actually be helpful!? – KevinMD
11. Not warning women about the transvaginal US when it is required (28) – Patient information sheet
    

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12. Performing hormone studies (FSH/LH/E2/Prog) to diagnose menopause or on every perimenopausal woman (20) – Australian Menopause Society diagnosis guidelines
13. Doing an ESR with every FBE (19) – Never indicated to do ‘routinely’ – FOAM4GP ESR & CRP
    
14. Acquiescing to requests for reverse T3, MTHFR etc. (tests without strong evidence base) (23) – Basic rule – don’t order a test you don’t know how to interpret with an evidence basis. Suggest they go back to the requesting practitioner. Screening tests of unproven benefit RACGP,
    
15. Not giving patients written advice on what they should do for their own care (8) – NHMRC – Communicating with patients
    
16. Checking lipids every year for primary prevention when low risk (30) – RACGP Red book (recommends 5yrly)
17. Prescribing sleeping tablets before sleep hygiene (26) – Sleep Hygiene Informed online. Can suggest always use non-pharm approaches first
18. Ordering TSH as a general screening tests on “check up” bloods (5) – TSH ordering guidelines – NPS
    
19. Ordering TFTs and not TSH in a ‘low suspicion’ or screening setting (3) – Though some labs do this anyway – Medicare will actually not bulk bill T3/T4 unless TSH is abnormal or other criteria is met – this is listed at the bottom of the page (1). – TSH ordering guidelines
    
20. Getting another doctor to “removal of stitches” after a procedure (9) – After care cannot be billed a second time. MBS guideline
    
21. Radiologists changing the “due date” on pregnancy scans without explaining why (17) – Recommendations at – 7.2 of the shared care Mater guidelines
22. Plain back xray in the absence of red flags (27) – WA Imaging guidelines
23. Sending women with breast lumps for US without clinical examination (8) – Breast symptom guidelines NHMRC
24. Antibiotics for abscesses and not incising when appropriate (12) – “Never let the sun set on undrained pus” WestJEM 2013
25. Not asking about migraine or DVT history when prescribing or re-prescribing COCP. Answers can change! (38) – Good general advice! History’s often change – Family Planning NSW
26. Antibiotics for painful teeth (13) – eTG has great freely accessible guideline on when to use ABs
27. Recommending OCP or POP as first line for contraception instead of LARCs. (25) – Sexual health and Family Planning Australia
28. Declining IUDs for nulliparous women (25) – They can be used simply and safely – Sexual health and Family Planning Australia
29. Continuing folic acid supplementation throughout entire pregnancy rather than just the first trimester (16) – They recommend for 1mth before conceiving and until week 12 unless there are other reasons- RANZCOG Vitamin and Mineral supplementation
30. Inappropriate prescribing of ABs eg. Augmentin for everything (24) – eTG recommended resource.
31. Prescribing COCP in patients with migraine with aura – WHO eligibility chart for contraception types
32. Doing chronic disease management plans and team care arrangements on patients who have another regular doctor (11) – Best performed by the patients regular doctor – CDM Point 1.8
    
33. Writing only minimal detail on a mental health care plan other than ‘depressed’ (11) – Templates for detail from RACGP
34. Ordering arbovirus or zoonosis tests just to ‘see if the patient has had them in the past’ (4) – Zoonoses – Tools for GP
    
35. Doing investigations which are not going to change management or provide prognostic information (10) – Testing times – RACGP
36. Referring a patient with PR bleeding for a colonoscopy without performing a PR exam (Pt’s have been seen who have had an anal cancer but were triaged low for colonoscopy because not checked) (7) – AFP 2010 – The bottom line
37. Prophylactic removal of moles because “the patient has a lot of them” (6) – Cancer.gov
38. Complaint of ‘smelly vaginal discharge’ – not looking, swabbing, examining – and prescribing random tinidazole or whatever (14) – STI guidelines Australia
39. Still performing DRE for prostate cancer screening (10) – Prostate.org – New guidelines 2016
40. Long time antibiotics for Lyme disease (10) –  If the patient even has Lyme unless they recently returned from an endemic area. Current Government guideline.
41. Approaching every nursing home patient assuming they are deaf, demented, and unable to make decisions.(11) – Silver Book RACGP
42. Stopping or starting allopurinol during an acute gout flare (8) – BPAC NZ
43. Not considering ‘quick start’ contraception in sexually active women (12) – Family Planning Victoria – Great table. Helps prevent ‘surprise’ pregnancy.
44. Not recognising or diagnosing PCOS – Jean Hailes
45. Using flucloxacillin for preschoolers – Caused BIG debate. Apparently the children HATE the taste. Long debate about best practice vs reality. “Most ghastly tasting concoction ever created – Grandmother” – Entertaining blog from a grandmother. Netmums
    
46. Assuming heavy periods are ‘normal’ and an expected part of being a woman. Offering OCP or hysterectomy as the only treatment options. Treating  with iron but not stopping the haemorrhage! (3) (13) – RANZCOG 2014
47. Fill in the appropriate forms for supporting patient travel schemes in your state (7) – Rural and regional National
48. Don’t order a battery of tests as a ‘check up’ (8) – Refer to RACGP Red book for appropriate follow up times
49. Treating “low serum iron” with iron supplements in normal ferritin etc. (3) – FOAM4GP While the Fe is hot!
50. Not registering your opioid requiring patients with relevant state body (11) – Eg QLD
51. Never stopping stuff! (eg Statins or PPIs) (15) – Deprescribing (NPS)
52. Ordering ANA’s in patients without high pre-test probability of rheumatoid disease (7) – Results are often confusing and unhelpful – RACGP ANA
53. Not avoiding opiates for non-cancer chronic pain at all costs! (6) – RACGP drugs of dependence
54. Prescribing medications (particularly specialists starting them) when they cannot be continued on the indication on the PBS (4) – PBS guidelines
55. Prescribing antidepressants as the first line treatment for mild/moderate depression (6) – Beyond Blue NHMRC Guidelines
56. Ordering a GCT instead of an OGTT in pregnant women (14) – RANZCOG
57. Not warning patients about possible out of pocket costs for some tests eg. Thrombophilia screen (if not fitting criteria) (6) – MBS
58. Continuing to use aspirin for primary prevention of cardiac disease (3) – MJA
59. Going on holidays without organising your chronic pain patients and drug addicted patients which you are managing are ‘handed over’ or appropriately supported (9) – Safe patient handover AMA
60. Recording allergies in the computer without stating what the issue was (3) – RACGP – Allergy? Adverse reaction? Intolerance?
61. Telling women to stop breastfeeding because of certain medications without checking or discussing with pharmacist (18) – LactMed
62. Telling patients to stop their high dose SSRI/SNRI without warning about side effects – SSRI discontinuation syndrome
63. Swabbing kids noses/throats for simple URTI and then treating with ABs if there is a bacteria there (7) – BroomeDocs
64. Performing xrays for low risk possible rib fractures (4) – AFP Thoracic imaging
65. Using Quetiapine for insomnia. Used off licence and don’t organise follow up (9) – NPS 2014
66. Performing a venesection for mildly elevated ferritins without haemochromatosis (4) – RACGP Elevated serum ferritin
    
67. Alprazolam. For anything really. (13) – There are much better options – Alprazolam AMA guidelines
    
68. Failing to recognise the possibility of an eating disorder (17) – RANZCP guidelines for eating disorders
69. Referring to a specialist colleague without an appropriate letter or work up. Gives GP’s a bad name (22) – FOAM4GP referral letter
70. Performing corticosteroid injections for tennis elbow (13) – MJA 2013
71. Doing an MRI of the knee for new minor knee pain without significant features or red flags (3) – WA imaging guidelines
72. Advising not to get sutures wet after a simple skin excision – BMJ 2006
73. Suggesting patients ‘swim in the salt water‘ with a wound – Expedition medicine, Scuba-doc
74. Starting beta blockers as first line for hypertension (7) – AHFoundation guidelines
75. Ordering exercise stress tests on intermediate or high risk patients instead of MPS / Stress Echo (3) – FOAM4GP Stress Test
76. Allowing chronic patients to think the solution to their pain is in a pill without addressing other lifestyle factors and education (10) – SA Guidelines
77. Neglecting lifestyle measures for patients with chronic diseases (7) – SNAP RACGP
78. Patients admitted to nursing homes without discussion of resuscitation/AHDs, EPOA, wills etc. (17) – RACGP Silver Book
79. Putting tired middle aged men on DHEAs (1) – Evidence is not strong and evidence of harms – Mayoclinic
    
80. Pre travel consultations without discussing multiple issues other than just vaccinations. Eg. safe sex, sunburn, safety, insurances, consent, medical condition mmnt etc. (11) – RACGP Travel advice
81. Giving repeat courses of ABs for a ‘cough’ without considering other causes eg. cancer, GORD, ACE inhibitor (5) – MJA CICADA Guidelines 2010
82. Daily dressings of non-healing leg ulcers without further investigation or referral as appropriate (10) – Wound healing guidelines
83. Starting statins in mildly elevated cholesterol without offering lifestyle advice or assessing absolute CVD risk (6) – CVD Risk Calculator
84. Leaving people on antidepressants/antianxiety medication for years without considering ceasing (6) – Psych UK “Coming off antidepressants
85. Adding on BP medications in a patient with high BP without checking if they are actually taking their other medication (6) – Compliance check
86. Not discussing with terminal patients where they would like to die eg. Home/hospital – Centreforpallcare.or
87. Continuing to prescribe medications with brand names even though the patient gets generic anyway. Just confuses everyone (12) – NPS guideline
88. Failing to stop (or starting) HCT in a patient with gout (4) – EBM Consult
89. Giving B12 injections where the only indications were “fatigue” and the B12 was “a little low” (6) – Medscape 2009
90. Specialists asking a GP to ‘organise an MRI’ as an outpatient without realising this will cost the patient a large amount of money. Allied health referring to GP to get ‘an MRI’ because ‘your GP can get you one’ (4) – RACGP MRI guidelines
91. Not avoiding the triple whammy – ACE, NSAIDs, and loop diuretics (5) – Kills kidneys TGA
92. The use of depo-provera without considering other better options without unknown risks of bone density problems (7) – ACOG 2014
93. Not getting images from the hospital! Important clinically to be able to review images yourself (4) – Surely we can fix this soon!
94. Prescribing bisphosphonates for years without review or BMD or lifestyle modification (5) – Eg. BMD every 2 years after starting – RACGP Osteoporosis
95. Allowing a patients Hba1c to remain high for many years without trying to create an appropriate target and lowering (2) – BPAC NZ 2010
    

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So there is the list. I certainly have changed a few things I do from the list. How did you go? Hopefully it was helpful!

Will repeat this again in the future and see if things change over time. In the meantime how can you help other doctors also?

Here is my suggestion:

Use this resource as printed out and left in a tea room as a conversation starter, use it in a teaching session with a registrar or medical student, or feed it to your dog (not sure how the last one will help other than maybe make you feel better!)

Give us some feedback – would love to know what people think. Let’s debate!

Cheers! – Doc Rob.

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(1) – “Thyroid function tests (comprising the service described in item 66716 and 1 or more of the following tests – free thyroxine, free T3, for a patient, if at least 1 of the following conditions is satisfied:
(a) The patient has an abnormal level of TSH;
(b)The tests are performed:
(i) for the purpose of monitoring thyroid disease in the patient; or
(ii) to investigate the sick euthyroid syndrome if the patients is an admitted patient; or
(iii) to investigate dementia or psychiatric illness of the patient; or
(iv) to investigate amenorrhoea or infertility of the patient;
(c) the medical practitioner who requested the tests suspects the patient has pituitary dysfunction;
(d) the patient is on drugs that interfere with thyroid hormone metabolism or function (item is subject to rule 9)”

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