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Australian Journal of Primary Health Australian Journal of Primary Health Society
The issues influencing community health services and primary health care
RESEARCH ARTICLE

General practitioners’ decision to refer patients to dietitians: insight into the clinical reasoning process

Sylvia E. M. Pomeroy A C and Robyn P. Cant B
+ Author Affiliations
- Author Affiliations

A Bayside General Practice Network, Cheltenham, Vic. 3192, Australia.

B School of Nursing and Midwifery, Monash University Gippsland Campus, Vic. 3842, Australia.

C Corresponding author. Email: spomeroy@iprimus.com.au

Australian Journal of Primary Health 16(2) 147-153 https://doi.org/10.1071/PY09024
Published: 19 May 2010

Abstract

The aim of this project was to describe general practitioners’ (GPs’) decision-making process for reducing nutrition risk in cardiac patients through referring a patient to a dietitian. The setting was primary care practices in Victoria. The method we employed was mixed methods research: in Study 1, 30 GPs were interviewed. Recorded interviews were transcribed and narratives analysed thematically. Study 2 involved a survey of statewide random sample of GPs. Frequencies and analyses of variance were used to explore the impact of demographic variables on decisions to refer. We found that the referral decision involved four elements: (i) synthesising management information; (ii) forecasting outcomes; (iii) planning management; and (iv) actioning referrals. GPs applied cognitive and collaborative strategies to develop a treatment plan. In Study 2, doctors (248 GPs, 30%) concurred with identified barriers/enabling factors for patients’ referral. There was no association between GPs’ sex, age or hours worked per week and referral factors. We conclude that a GP’s judgment to offer a dietetic referral to an adult patient is a four element reasoning process. Attention to how these elements interact may assist clinical decision making. Apart from the sole use of prescribed medications/surgical procedures for cardiac care, patients offered a dietetic referral were those who were considered able to commit to dietary change and who were willing to attend a dietetic consultation. Improvements in provision of patients’ nutrition intervention information to GPs are needed. Further investigation is justified to determine how to resolve this practice gap.

Additional keyword: nutrition.


Acknowledgements

This work was supported by a scholarship awarded to SEMKP from the Victorian Health Promotion Foundation (Vic Health).


References


Ammerman A, deVellis RF, Carey TS, Keyserling TC, Strogatz DS, Haines PS (1993) Physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement. Preventive Medicine 22(1), 96–109.
Crossref | GoogleScholarGoogle Scholar | PubMed | CAS | [Verified 18 February 2009]

Commonwealth Department of Health and Aging (2009) Towards a national primary health care strategy: a discussion paper from the Australian Government. Available at http://www.ag.gov.au/cca [Verified 18 February 2009]

Counterweight Project Team (2004) Current approaches to obesity management in UK primary care: the Counterweight Programme. Journal of Human Nutrition and Dietetics 17(3), 183–190.
Crossref | GoogleScholarGoogle Scholar | PubMed | [Verified 30 March 2009]

Higgs J , Jones MA (2008) Clinical decision making and multiple problem spaces. In ‘Clinical reasoning in the health professions’. (Eds J Higgs, MA Jones, S Loftus, N Christenssen) pp. 4–14. (Butterworth Heinemans: Amsterdam)

Holli BB , Calabrese RJ , O’Sullivan-Maillet J (2003) ‘Communication and education skills for dietetics professionals.’ 4th edn. (Lippincott Williams and Wilkins: London)

Holmes AL, Sanderson B, Maisiak R, Brown A, Bittner V (2005) Dietitian services are associated with improved patient outcomes and the MEDFICTS dietary assessment questionnaire is a suitable outcome measure in cardiac rehabilitation. Journal of the American Dietetic Association 105(10), 1533–1540.
Crossref | GoogleScholarGoogle Scholar | PubMed | [Verified 21 February 2009]

McInnes D, Saltman D, Kidd M (2006) General practitioners’ use of computers for prescribing and electronic health records: results from a national survey. The Medical Journal of Australia 185(2), 88–91.
PubMed | [Verified 26 February 2009]

National Health and Medical Research Council (2004) ‘Clinical practice guidelines for the management of overweight and obesity in adults.’ (Department of Health and Ageing: Canberra)

Nicholas LG, Pond CD, Roberts DC (2003) Dietitian-general practitioner interface: a pilot study on what influences the provision of effective nutrition management. The American Journal of Clinical Nutrition 77(Suppl. 4), 1039–1042. open url image1

Norman G (2005) Research in clinical reasoning: past history and current trends. Medical Education 39(4), 418–427.
Crossref | GoogleScholarGoogle Scholar | PubMed | open url image1

Pomeroy SEM, Worsley A (2008) Nutrition care for adult cardiac patients: Australian general practitioners’ perceptions of their roles. The Journal of Family Practice 25(Suppl. 1), 123–129.
Crossref | GoogleScholarGoogle Scholar | open url image1

Richards L (2005) ‘Handling qualitative data – a practical guide.’ (Sage Publications: London)

Schwartz A , Elstein AS (2008) Clinical reasoning in medicine. In ‘Clinical reasoning in the health professions’. (Eds J Higgs, MA Jones, S Loftus, N Christenssen) pp. 233–235. (Butterworth Heinemans: Amsterdam)

Sikand G, Kashyap ML, Wong ND, Su JC (2000) Perspectives in practice. Dietitian intervention improves lipid values and saves medication costs in men with combined hyperlipidemia and a history of niacin noncompliance. Journal of the American Dietetic Association 100(2), 218–224.
Crossref | GoogleScholarGoogle Scholar | PubMed | CAS | open url image1

Sundararajan V, Bunker SJ, Begg S, Marshall R (2004) Attendance rates and outcomes of cardiac rehabilitation in Victoria, 1998. The Medical Journal of Australia 180(6), 268–271.
PubMed | open url image1

Tashakkori A , Teddlie C (1998) ‘Mixed methodology: combining qualitative and quantitative approaches.’ (Sage Publications: London)