Family Practice Vol. 18, No. 2, 195-198
© Oxford University Press 2001
The management of thyroid disease by GPs
Cattedra di Endocrinologia, Dipartimento di Medicina Interna e Scienze Biomediche, Università degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy.
Negro R, Dazzi D and Pezzarossa A. The management of thyroid disease by GPs. Family Practice 2001; 18: 195–198.
Received 17 February 2000; Revised 22 June 2000; Accepted 30 October 2000.
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Abstract |
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Background. Good medical practice depends on a collaborative relationship between a GP and a targeted specialist.
Objective. The aim of the present study was to assess knowledge and management by GPs of common endocrine disorders such as thyroid diseases.
Methods. We submitted to all the GPs (622) of the Province of Lecce an anonymous questionnaire with 11 questions which aimed to evaluate methods of approach to (questions 1 and 2) and knowledge about (questions 3–11) thyroid diseases.
Results. (i) Most GPs (72.1%) evaluate thyroid function on the basis of a clinical suspicion and perform preliminary investigations before referring the patient to a specialist. (ii) The ratio between right and wrong answers was significantly higher for four questions, significantly lower for one question and distributed by chance for four questions. (iii) The degree of knowledge strictly corresponds to the GP's attitude to patient's management.
Conclusions. For a thyropathic patient to be diagnosed rapidly and treated efficiently, it is necessary to disseminate knowledge of standardized protocols to ensure a better utilization by both the GP and the endocrinologist of their respective competences.
Keywords. Drugs affecting thyroid function, family practice, thyroid.
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Introduction |
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The role of the GP in health care supply is pivotal. The GP often seeks a specialist's advice in order to deal with diagnostic or treatment procedures. The results of this collaboration influence the therapeutic result, the costs of obtaining it, and the patient's satisfaction. Both the preliminary medical procedures and the provision of health care after specialist intervention are a GP's duty. Thus, good common knowledge is needed to minimize misunderstandings and waste of time (and/or money) due to performing too few or too many relevant tests.
We have focused our attention on diseases of the thyroid gland because they are widely represented in Italy 1 and their management is suitable for shared patterns of health care. Therefore, we sought to discover the procedure options followed most frequently by GPs and to find out the diagnostic and/or therapeutic difficulties encountered by GPs in this field.
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Methods |
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A questionnaire comprising 11 questions (Table 1
) was sent to each GP member (622) of the Medical Doctors Association of the Province of Lecce. Lecce is a southern Italian town of 100 000 inhabitants, and is the major town of a coastal province comprising almost 1 million inhabitants. Statistic evaluation of the data was done with chi square analysis and Fisher's exact test; a P-value <0.05 was considered significant.
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Results |
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A total of 122 out of 620 (19.7%) questionnaires were returned. Two undelivered questionnaires were returned to sender. Table 1
shows the questions, the relative distribution (chi square test) of answers, and whether these were correct (T) or incorrect (F), divided into three groups of respondents: (IR) GPs who immediately refer the patient to the endocrinologist; (SC) GPs who share the care with the endocrinologist; and (CT) GPs who care for the patient themselves. |
Discussion |
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The results of this study allow us to understand the GPs' attitudes to and knowledge about thyroid diseases.
The percentage of responders was quite low (20%). This highlights a low sensibility about this condition, even taking into account that the nearest referral centre for thyroid diseases is 150 km from Lecce. Furthermore, the picture obtained could be even worse considering that those GPs who responded are at least more interested in thyroid diseases than those who did not respond.
A clinical suspicion rather than a genetic predisposition or a routine check is the main reason why GPs ask for an evaluation of thyroid function. However, selective testing based on clinical signs has been suggested not to be effective in current practice.11
Once a thyroid disease is diagnosed, the GPs' management of the patient is divided into three attitudes (P < 0.0005): group 1 (15%) refer the patient to the endocrinologist without preliminary investigations then follow his advice; group 2 (72%) share the care with the endocrinologist; and group 3 (13%) assume the entire responsibility for diagnosis and treatment.
There is a different degree of knowledge among the three groups (P < 0.02). In group l, we found a lesser degree of knowledge (wrong answers: >4 out of 9) than in group 2 (P < 0.0001) and group 3 (P < 0.01).
From the answers obtained, we can infer that the patient usually is evaluated by the endocrinologist, then the requested investigations are performed and finally the patient is re-evaluated in order to define the treatment. Thus, there are many drawbacks: first, a waste of time before starting treatment; secondly, the GP entrusts his patient to the specialist for the follow-up even when the condition is not particularly difficult to deal with; and, finally, the patient could lose confidence in his GP since he could think that the GP is only able to care adequately for more common health problems.
The most common behaviour was for the GPs to perform some biochemical and/or instrumental investigations before referring the patient to the endocrinologist. In this way, the patient can save time and the specialist will be able to make the diagnosis and apply the consequent treatment more easily and earlier. The knowledge in this group was quite good, as wrong answers were given to about three out of nine questions. With regard to questions 7–11, 54% of respondents gave 3–5 wrong anwers. As these mistakes concern pivotal matters, they can involve a considerable waste of time for the patients and of money for the National Health Service. A thorough knowledge would allow the GP to manage the laboratory and therapeutic follow-up (e.g. levothyroxine settlement in hypothyroidism or nodular goitre) himself in order to save time and money and increase his patient's confidence in him.
The smallest group is made up of doctors who plan a correct laboratory and instrumental evaluation and then start the treatment without specialist counselling. The average number of wrong answers in this group is about two out of nine; with regard to questions 7–11, none gave more than two incorrect answers. Thus GPs' knowledge about thyroid disease in this group is good.
In conclusion, the GPs' attitude to management of thyroid diseases is defined quite strictly by their degree of knowledge. Overall knowledge is really good regarding the usefulness of dietary iodine; unsatisfactory regarding drugs affecting thyroid function; and poor regarding the proper use of laboratory tools.
Thus, the thyroid patient represents a difficult problem for GPs. Since the largest group comprises doctors who perform preliminary investigations before referring the patient to the endocrinologist, we believe that formulation, diffusion and use of standardized protocols for patient management could avoid discomfort and waste of time for the patients and waste of money for the National Health Service.
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References |
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