Pathology testing and the interpretation of results are regular challenges for many GPs, and there are several key areas that are particularly problematic, an AusDoc survey of 418 GPs and GP registrars has revealed.

1. Ordering tests: vague symptoms pose problems

When it comes to deciding which pathology tests to order, the clinical presentations that GPs find most difficult are “vague” symptoms, with “fatigue”, “tiredness”, and “non-specific” symptoms reported as the most troublesome.

Respondents noted: “Unexplained weight loss or fatigue. Broad differentials could include malignancy, autoimmune disease or other serious pathology that I don’t want to miss.”

“It’s very time consuming to gather all the facts – and basic screening pathology, while helpful, is seldom definitive.” Pain symptoms were also a challenge. One GP reported: “Abdominal pain [can be difficult] as it encompasses inflammatory, infective and neoplastic causes. Bloods, faeces tests and radiology are all used in diagnosis.”

2. Test interpretation: autoimmune conditions are a big challenge

Many GPs struggled with interpreting test results for autoimmune conditions and rheumatological disorders. Here’s what they had to say.

“Autoimmune and cancer markers…positive and negative results can be equally important, but also vague. How to translate what they mean to a specific patient is extra challenging and time-consuming.”

“ANA results. These reports can be quite vague and therefore unclear if relevant to my patient’s presentation.”

“Autoimmune / rheumatological tests [can be challenging] as negative results don’t exclude a problem and make the next step more difficult.”

Hormone testing and iron tests were also common challenges, the survey found.

A key issue was the clinical significance of results. Test results that left GPs wondering how to proceed included:

  • low rise in PSA
  • mildly elevated calcium
  • new elevation liver function tests without symptoms or apparent steatosis
  • increased creatinine, especially in a young person
  • unexpected results from parathyroid hormone levels
  • high cholesterol status in the setting of a zero calcium score.

3. Pressure from patients

The RACGP advises: “To prevent harm to patients, meet professional obligations, reduce medico-legal risk, and ensure appropriate use of the Medicare Benefits Schedule (MBS), GPs should only request medical imaging and pathology tests that are clinically indicated.”

The survey indicated that patients request iron and cholesterol tests above all others, followed by PSA testing and hormone testing. However, the challenge comes when patients want a raft of unnecessary tests, presenting with “I just want to get everything checked to make sure I’m ok”. This causes multiple issues.

Some patients view GPs as a service for their consumer needs, so explaining clinical need in a tactful way can be difficult. “Typically, patients seem to have the expectation at presentation that the GP visit is a formality, and we have no reason to decline these investigations. I have had colleagues who have provided forms for medically relevant tests, then had the patient alter the request form afterwards.”

Complementary health providers or other health professionals can also create problems in the GP consult room. One respondent said: “Patients presenting with long lists of tests – which are generally not required – from naturopaths or other ‘alternative’ health providers. Patients often take the attitude of ‘why not?’ just order testing. It is extremely time-consuming to try and discuss why some tests are or are not indicated.”

Conclusion

Australian GPs are ordering and interpreting literally millions of pathology and other diagnostic test results regularly – 204.1 million Medicare-subsidised tests in 2020–21, according to the AIHW.

However, many GPs feel uncertain about ordering and interpreting tests.

The Royal College of Pathologists of Australasia (RCPA), in conjunction with Australian Doctor, has created a series of educational pieces in the Common Sense Pathology series, but GPs are calling for more education in the pathology space.  Can pharmaceutical companies involved in the treatment of rheumatological or autoimmune conditions offer GP education on appropriate pathology to help close the knowledge gaps?

Perhaps pathology companies or the RACP can create medical education programs and guidance on which tests to order when a patient presents with vague symptoms. Or perhaps pathology labs or the RACP can offer clearer guidance on appropriate next steps for practitioners following lab test results. There are many educational opportunities – and GPs are hungry to learn.

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References

[i] AusDoc Survey: GP understanding and behaviours in ordering and interpreting pathology tests (October 2023), n=418 (95% GPs, 5% GP Registrars).

[ii] RACGP. Position statement: Responding to patient requests for tests not considered clinically appropriate. Available online: https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/clinical-and-practice-management/responding-to-patient-requests-for-tests

Accessed 13/2/24.

[iii] Australian Institute of Health and Welfare. Pathology, imaging and other diagnostic services. Last updated 7 July 2022. Available online: https://www.aihw.gov.au/reports/diagnostic-services/pathology-imaging-and-other-diagnostic-services.

Accessed 13/2/24.