A.Helman
Note: this is the text of a presentation given at the International Workshop on Nutritional Attitudes and Practices of Primary Care Physicians held in Heelsum, Holland in December 1995. It has been accepted for publication in the American Journal of Clinical Nutrition, but is placed on the Internet for the time being to stimulate debate. I would welcome email with any comments.
Background
Australia has a government subsidised, private medical system in which general practitioners
(GPs) form a core component of primary care. It is estimated that in any twelve month period
80% of the population consults a general practitioner 1, of which there
are approximately 20,000 in active practice 2. The GP therefore has
a major role to play in implementing nutrition policy.
In the last few years, general practice in Australia has undergone major changes. Most general practitioners are on a vocational register, which requires them to undertake formal continuing education and quality assurance. To enter this register, all GPs must now complete training which is currently offered only through the Royal Australian College of General Practitioners (RACGP).
Another significant element in the organisation of general practice are the Divisions of General Practice. These are grass roots groupings of GPs in each geographical region which are eligible for government funding for activities such as community prevention, continuing education, research and employment of paramedical personnel, including dietitians 1.
Australian research
Three types of research have contributed to our understanding of Australian GPs'
practices, knowledge and attitudes towards nutrition:
1. Academic studies (table 1): typically characterised by representative samples, good response
rates and detailed information.
2. Commercial surveys (table 2): focus groups and telephone surveys conducted by market
researchers add to the qualitative understanding of the issues involved, but often have poor and
undocumented response rates, are likely to be atypical samples and may have a specific
commercial focus. Another valuable source of data are the annual surveys conducted by medical
mailing list companies, which reach almost the entire medical practice population.
3. Needs assessment for continuing medical education: Divisions of General Practice engage in
regular surveys into the educational needs and preferences of GPs in their area.
| Study author | Year of study | n= | Response rate | Refs. | Focus of sample and/or study |
|---|---|---|---|---|---|
| Helman | 1986 | 248 | 52% | 3 | Vitamin prescribing |
| Judd | 1987 | 213 | 75% | 4 | Weight management |
| Koppe | 1987 | 25 | 90% | 4 | Dietary assessment tool for GPs |
| Koppe | 1988 | 33 | 92% | 5 | Accuracy of weight management advice |
| Porteus | 1989 | 283 | 75% | 6 | Attitudes, knowledge, practice |
| Worsley | 1990 | 757 | 78% | 7 | NZ GPs information needs |
| Helman | 1991 | 64 | 72% | 8 | Comparison with dietitians, naturopaths |
| Hughes | 1995 | 71 | 35% | 9 | Rural GPs and other health professionals |
| Study author | Year of study | n= | Response rate | Refs. | Focus of sample and/or questions |
|---|---|---|---|---|---|
| Market Research | |||||
| Sudler & Hennessey | 1995 | 150 | 5% | 10 | GPs |
| Australian Dairy Corp. | 1995 | 100 | ~15% | 11 | GPs, dairy products |
| Meat Research Corp. | 1995 | 96 | ~ 15% | 12 | GPs, meat |
| Mailing list companies | |||||
| IMS | 1995 | 20,737 | 99% | 13 | All doctors |
| AMPAS | 1995 | 19,922 | 99% | 2 | All doctors |
In mailing list surveys in which doctors have been asked to list their special interests from a large range of options 15-17% of GPs have declared a particular interest in nutrition 2,13. This places GPs in the mid-range of medical specialties, well below groups such as gastroenterologists (80% interested in nutrition), paediatricians (77%) and public health physicians (23%), but above internal medicine physicians (16%), palliative care specialists (7%) and cardiologists (3%) 2. A higher proportion of female GPs are interested in nutrition (20%) compared with men (13%). Interest is also greater in more recent graduates 14, although those who graduated most recently show less interest than those who have been in practice for at least ten years 13, which may reflect the benefit of some practical experience with patients in realising the importance of nutrition.
When asked about the circumstances in which they give nutrition advice, GPs have self- reported that they give such advice in 17% of consultations 8. The majority of this is initiated by the GP and is disease-specific rather than general information on healthy eating (table 3 ref: 6). Several studies have shown that the main conditions for which advice is commonly given are heart disease, hyperlipidaemia, obesity and diabetes. Many other conditions attract nutritional advice, but much less commonly 6, 9,11. These findings are consistent with overseas research 15 and reflect the relative importance of these diseases in national mortality 16. In some cases, GPs are clearly missing potential cases of nutritional disorder - in one unpublished study of Australian GPs, they reported diagnosing an average of only 1.2 cases of paediatric iron deficiency in the preceding twelve months 17, despite the fact that the condition has a prevalence of 2-20% in various Australian paediatric age and population groups 18, 19.
| Who raises the subject? | Patient | 31% of time | GP | 69% of time |
| What sort of advice? | |
| General healthy diet | 37% |
| Disease-specific | 63% |
A number of studies have surveyed nutritional attitudes of Australasian GPs 3, 6, 9,14. When asked their view on the importance of nutrition to health or medical practice, most responses have been very positive. For example, 76% agreed that "diet has a significant impact on long-term health" and 96% that the GP can be "influential in getting the patient to change their diets" 4.
However, there seems to be a `halo effect', in that these positive attitudes are not always consistent with behaviour. For example 63% of GPs agreed that "faulty nutrition is the major cause of disease in adult Australians" 8 - a strong statement, belief in which might be expected to lead to higher rates of nutritional counselling than have been so far reported.
Perhaps part of the reason for this inconsistency lies in the obstacles to nutrition counselling reported by Australian GPs, chief amongst which were lack of time, lack of confidence and inadequate nutrition knowledge (table 4 refs: 4,10). These obstacles are not unique to nutrition but have been reported as applying to many preventive activities 1. In focus groups, GPs have also mentioned their frustration with the apparent frequency with which the nutrition orthodoxy appears to change its mind on important issues, for example the role of fats in heart disease 10. It is reasonable to suppose that confidence in ability to give nutritional advice might be linked to objective level of nutrition knowledge. Surprisingly at least two studies have failed to find any such relationship, something which is perhaps reason for concern 8, 9.
However, GPs' perception that they lack nutrition knowledge appears to be well founded. When tested for nutritional knowledge, rural GPs scored poorly 9. In an inter-professional comparative survey, GP nutritional knowledge scores were low in comparison to dietitians and even naturopathic students, whilst medical students scored very poorly indeed (table 5 ref: 8). Studies of GPs nutritional beliefs show they tend to be consistent with official dietary guidelines, but at the same time they show leanings towards alternative viewpoints in certain areas, such as the possible dangers of food additives and the role of vitamin supplements 3, 8, 14, 20.
| Lack of time | 31% |
| Lack of confidence | 16% |
| Lack of knowledge | 14% |
| Patient's attitudes | 16% |
| Financial | 11% |
| Other | 12% |
| GROUP | Professionals | Students | t-test * |
| General practice (n =) | 2.9 (64) | 1.5 # (27) | p<0.05 |
Dietetics
| 6.5 (40) | 6.3 (17) | p>0.05 |
Naturopathy
| 1.4 (34) | 3.4. (50) | p<0.05 |
There is no doubt that interest in nutrition amongst GPs is strong and growing, that they recognise a lack of adequate knowledge in this subject and are keen to be learn about it 9, 10, 21. In educational needs assessment surveys undertaken by Divisions of General Practice, for example, nutrition consistently appears as a priority for GPs 21. In part this interest is being driven by `consumer' pressure to meet patient interests and in part by recognition of the clinical importance of nutrition 11.
The great paradox in GP nutrition at the present time is that, despite this level of interest, there is still little coherent teaching on the subject, particularly teaching specifically tailored for GPs. The RACGP training program has until recently not had any core general practice curriculum and certainly no policy on teaching nutrition. Established GPs have even less structure to their continuing medical education. Educational events are run by a wide variety of providers (including pharmaceutical companies) each following their own agenda. Whilst there may be nutrition content within these educational programs, nutrition topics in their own right are not often seen.
When asked about their preferences for nutrition education, GPs have expressed interestin a wide variety of learning formats, including seminars and distance education 7, 9. But priority tends to be given to educational material (such as diet charts) to give to patients. In a study of New Zealand GPs, pamphlets and patient information kits were the two highest preferred educational options 7. Whilst this may show GPs' nutritional interest, it might also reflect a preference not to have to deal with the patient's diet in any detail themselves.
New initiatives
There have been a number of promising recent initiatives in relation to nutrition in Australian general practice. At the undergraduate level, several universities have made academic nutrition appointments specifically to work with medical students, with positive effect on nutrition interest amongst both students and GPs in the surrounding area 22. New medical courses based on post-graduate entry and case-based teaching are being introduced in some medical schools, providing fresh openings for nutrition teaching. In GP training, the RACGP has started to define a core curriculum for general practice registrars, and it is anticipated that there will be a nutrition input into this process. For established GPs, the College is developing a practice assessment option (under the quality assurance program required of all vocationally registered GPs) in which GPs identify and assess nutritionally at-risk patients within their own practice. Accompanied by a case-based teaching video, this option will be offered in conjunction with a two day course currently being designed to teach GPs the basic elements of clinical nutrition in general practice. A medical publication widely read by GPs now runs a regular nutrition column.
The RACGP has recently had a Nutrition Advisory Group to advise the Secretary-General
on matters of nutrition policy. This group will also seek to take a pro-active stance in defining
GP nutrition curriculum, working with other providers to encourage delivery of more GP
nutrition education, and seeking input into outside committees and panels involved which are
formulating public health nutrition policy likely to involve GP participation. The Australian Iron
Status Advisory Panel is a good example of such a nutrition public-health oriented body which
focuses its public health strategy on GP nutrition education and which has three GP members
on the
panel 23. Another recent example is the Nutrition Screening
Initiative, where the RACGP has worked with community and specialist groups to implement
a program to enhance GPs awareness of nutrition screening, particularly in the elderly
24.
Future directions
The discrepancy between the level of GP interest and the lack of nutrition education resources has already been highlighted. What is needed above all is not just a greater quantity of material, but resources which are part of a coherent, coordinated vision on what constitutes good general practice nutrition. This requires firstly a clear understanding of the scope of nutrition in general practice. Unfortunately GPs tend to think of nutrition initially mainly in terms of cardiovascular, obesity and diabetic disease10, conditions where compliance and beneficial long-term outcomes may not be so easy to accomplish. A broader understanding of the scope of nutrition in general practice will also emphasise patients and conditions which may be easier and more immediately rewarding to treat, such as iron deficiency, sports, pregnancy and geriatric nutrition. This is likely to enhance GPs' enthusiasm and confidence.
The second important requirement is that nutrition teaching be specifically tailored for GPs. The GP perspective tends to be much more pragmatic, case-based and less theoretically focussed than many specialists or dietitians realise. This inevitably means that substantial GP input is needed for any successful educational initiative for GPs 25, something which has often been lacking in general practice nutrition education. It is not only the style of teaching, but the methods and approaches for practising clinical nutrition which need to be made suitable for the unique environment of general practice. When efforts have been made to tailor methods of nutritional assessment and treatment specifically for the GP, this has well received 5, 14.
On the research side, Australian studies on nutrition and general practice have so far been mainly descriptive, and in large part based on self-report. What is now needed is objective evidence of what GPs actually do, rather than what they say they do or think they should do - things which have been shown to be very different 26. Such research will allow us to reach more sophisticated models of how clinical and preventive nutrition fits into the context of general practice. Ultimately it will lead to practical approaches which enable GPs to effectively implement nutrition interventions in their own patients.
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References
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2. Australasian Medical Publishing Company. Unpublished data.
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University of Sydney, 1986.
4. Judd H., Weeks R, Koppe H. Management of obesity in general practice: report
from the nutrition fellowship 1987. Sydney: Royal Austr College of General Practitioners, 1988.
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