What GPs know about asthma

Are general practitioners no good at treating asthma? “GPs poor asthma training ‘risks lives,’” said the Independent recently, sternly warning that “Asthma UK says a survey found that 47% of GPs admit that their own knowledge about the condition could be better . . . it estimates at least 45 million could be saved if GPs were better informed and care was better managed” (3 May 2011, www.independent.co.uk/life-style/health-and-families/health-news/gps- poor-asthma-training-risks-lives-2278053.html).

The free Metro newspaper went with “Asthma deaths ‘could be cut with GP training,’” saying that doctors’ “education on the chronic condition is not a priority despite more than half of GPs agreeing that the number of deaths could be reduced with better care. Just under two thirds said that they felt that public awareness of asthma could be improved, while 47% admitted their own knowledge was lacking. This reflects a Primary Care Respiratory Society survey in which more than half of the GPs questioned gave incorrect answers on clinical guidelines for asthma” (2 May 2011, www.metro.co.uk/news/862143-asthma-deaths-could-be-cut-with-gp-training).

Neil Churchill, chief executive of Asthma UK, said on BBC Radio 5 Live, “Unfortunately, the majority of GPs got questions wrong, in fact over half of GPs answered incorrectly in eight out of 10 questions they were asked about asthma clinical guidelines. So it’s probably not surprising therefore that the majority of GPs—nearly two thirds—said that education for healthcare professions could be improved.”

The interviewer, taken aback, asked, “Asthma’s not an uncommon condition, so it seems surprising to suggest that there is this lack of knowledge?” “We think that standards in asthma have probably slipped in recent years,” Mr Churchill replied, saying that asthma admissions and deaths were now static. “We can’t afford to have someone end up admitted to hospital every seven minutes with an asthma attack, for what is pretty much a treatable condition with modern medicine” (www.bbc.co.uk/news/health-13270027).

These are serious allegations about doctors’ knowledge, so what’s Asthma UK’s evidence? The press release that the charity released (on “world asthma day”) cited two surveys (www.asthma.org.uk/news_media/media_releases/gps_agree_that_asthm.html). The first had results from 1001 general practitioners, was funded by Asthma UK, and completed by GfK Healthcare, a market research company. This questionnaire asked general practitioners their views about their knowledge and training concerning asthma. The second survey was performed by the Primary Care Respiratory Society. It involved asking people who were visiting their website looking for asthma guidelines to defer reading the guidelines and answer a set of multiple choice questions. People were asked for their job title and told, “We’d like you to take the short survey on this page before you look at the guide” (www.pcrs-uk.org/asthmaguide).

It would therefore seem that this was a select group of people who had wanted to look at the guide and who might therefore have had questions they wanted to ask. The participants were not told that their results would be formally reported or indeed that campaigning groups would use their results as evidence of their knowledge (or lack thereof).

Writing up their findings as a “short report” in the Primary Care Respiratory Journal, the authors noted that out of 3560 hits on this part of the website, 413 went on to fill in the questionnaire (2010;19:180-4, doi:10.4104/pcrj.2009.00052). Of these, 96 described themselves as general practitioners. Despite being in the minority of respondents, general practitioners were the only group mentioned by Mr Churchill on both the BBC and, the same day, by him on a Guardian web debate. Here he repeated that the study by the Primary Care Respiratory Society showed that “half of GPs answered incorrectly in eight out of ten questions about clinical guidelines for asthma” (www.guardian.co.uk/society/blog/2011/may/03/nhs-reforms-live-blog?commentpage=all#start-of-comments).

Not only was the use of the results withheld from participants, but when the results were publicised, it was not equally clear that the website was sponsored by an “educational grant” from the drug company GlaxoSmithKline. Hilary Pinnock, lead author, described the published report to me as a “quick and dirty” paper of which the authors were aware of many flaws that are listed in the paper.

Indeed, it was not clear which respondents even completed all of the questions; some people may have only filled in one or two and scored zero on the remainder. The questions themselves were so guideline based as to be confusing—for example, the first question asked, “In which group of children should clinicians take the following approach? Watchful waiting with review: (a) Those with a high probability of asthma; (b) Those with a low probability of asthma; (c) Those with an intermediate probability of asthma.” The correct answer was (b) because the guidelines class children already with symptoms that could suggest asthma into these three probability groups. But it was not clear from this question that it was about children with symptoms. And each of the four authors declared sponsorship, honorariums, travel, or consultancy fees from a total of 16 drug companies.

Asthma UK declined to say how much it spent on its survey, and it was only on questioning for this article that GfK Healthcare said that 9200 general practitioners were initially contacted, giving a response rate of only 10.9%. Mr Churchill has told national radio that general practitioners don’t know enough about asthma. Doctors have a professional obligation to keep well informed and up to date. Is it fair that they also have mistrust in them engendered by surveys that do not have the strength to justify them? If healthcare charities want to be taken seriously they should not be in the business of using weak research to satisfy their aims.