The Dumbing Down of General Practice

Is GP work being “Dumbed Down”??

In a recent advert by some consultant they are charging a lot per person to say how they should protect themselves from any future litigation arising from a patient contracting some infection from some type of surgical intervention at their practice. This is trading on the concerns / worries guilt that all GP’s have, because no matter how secure their Practice Protocols, how great their case notes—there is still the possibility of being sued for patient outcomes that either did not arise from faulty patient management.

In the example the person providing the session said that in the event of a patient contracting Hep C it could be seen that it could have arisen from recent surgical intervention and that our records / sterilisation may prove unable to defend us.

At first sight it might be simpler to either contract out the sterilisation or simply not to do any work like that. This is in the path of action that might follow if you are challenged for a “missed diagnosis”. So you begin to refer everybody – that cough for one week gets an xray ?? lung cancer etc.

In the end you ability to manage any problem which is even slightly complex becomes eroded. Partly because of a lack of information / partly the lack of numbers seen with that problem. So it means that you long to get out of your practice and become a locum. This partly helps because you are less likely to be blamed if you do not see that patient in a longitudinal management. You also refer more but in the end you become totally “dumbed down” It becomes less satisfying.

So what is the answer??
One way would be to construct protocols / check lists / systems to cope. In this way if the parents of a child with a positive heel stab contact you then I should be able to look up what tests would have been done and what are the management strategies. It would be ongoing and never finished updating this information.

But even as I write this I have the niggling thought “Is it worth it all?” In view of GP’s having to see lots of patients in order to make a living and not to have long consults – are protocols etc the way to go. No!! The government has created this monster and destroyed medicine so just give up. Smile and refer. However I cannot do this. I will keep trying the protocol way.

Interesting Patients

Patients who have fantasies
Another issue is the high class female patient who has fantasies that they need medical attention and that they are sick. My interaction ius always interesting as they seem to be a lot more up front and direct with the doctor. The examination of these patients is always interesting as well because you do not want to miss anything.
Especially with this sort of patient you should be dressed appropriately as they will also tell you if you are not dressed correctly. Often your hands are tied as regards what you can do but eventually you are able to examine and deal with the situation in a proper manner. Such examination needs to be detailed each time – with nothing missed.
These sorts of patients need to be seen often so that it keeps me up to the mark, then when you have a successful consult it is a good feeling
These patients have a lot of problems and need to be reviewed at least every 2-3 months. Then anxiety levels will not rise.

Yet another report on health!!

Change and the GP

The thing that sparked off this was the National Health & Hospitals Reform Commission Report.  This is one of the many reports and changes that have been proposed and been coming on the scene for the last 2 years—on top of changes for health care plans.  I would like to try and work through the changes and why I am upset about it all (actually profoundly depressed).  Then to work out what should be my own individual response.   It is important that I do this because I still have some time left in working as a GP Locum and I have to get things right.

 

What these plans have done is to put on top of a patient management system a whole lot of extra administration that does not achieve anything except get a physio at a cheaper rate for the patient.  (reverse referral)  If we do not use them for our other long term CDM patients then we deprive ourselves of income.

 

We all had a sense of purpose as GP’s and that is to assess, diagnose and manage a patient’s problems. In order to survive we have to be crystal clear and focussed with this..

 

I have to sort out things and use a USB stick to transfer data e.g. Mental Health Plans.  I do not expect any follow up but these things will be requested.  So in doing this I can get the referrals done and also continue to manage the patient as I have always done.  The reason is that in changing over to other different ways of conducting a General practice they all collapse in the end – usually due to financial reasons.  So it is best to stick to the old ways and graft these other systems onto what I do.

 

In this way I will not become demoralised or disillusioned.  The next generation of doctors will attempt to go along with it all and seemingly make progress but they will collapse because of financial constraints.  They will join bigger units to financially survive and not care too much about Chronic Disease Management. They will be good and focus on a professional job, much like a hospital doctor does now…  Targets will come and go.  Bundled health care will come and go.  Others in the management will have to work it all out.  These doctors will not!!  Doctors will consult in the least aggressive manner and not work too hard.  Making $$ will be a main factor. 

 

For me I will seek episodic practice and rural work.  As regards these care Plans etc, unless the practice has a mechanism in place  I will not attempt to manage patients in a long term sense.

 

So I need to develop diagnostic programs like Tiredness etc so I can manage people and then troll back through chronic management plans.

 

In order for this to work a practice would need a database program that says in effect that today you as a doctor need to check BP check lipids manage obesity what is Hb1ac?  As a separate consultation.  Need to monitor if patient has gone to ophthalmologist, podiatrist. 

 

If none of this happens and a care plan in place then pick on 1 thing and note that you have requested it.  Put this at the end of the normal consultation Or say that I notice that there a lot of different things wrong and that we need to sort them out at a future consult (which will be made but not kept)

Changes to delivery of Primary Health Care

Changes to Primary Health Care delivery
Once again the Federal Govt has excelled itself in red tape. what it is trying to achieve is a reduction in what is termed “avoidable hospital admissions”
I would suspect that they really have not looked at these cases but only went on anecdotal evidence. The idea was that GP’s do not really look after patients when it all gets too hard, but slough them off to the Hospital Even more so after hours. The reality is that there are more and more frail sick people with multiple problems for which there comes a time when the GP can no longer manage them in an ambulatory clinic situation. House calls are a part answer, but it is not cost effective.

So in an effort to manage the patients “better” it is proposed that they be more closely managed by a single clinic. Of course it will change nothing. The end point will still come and referral to a hospital will still happen to them. CMA / Team Care was tried and it has made no differerence. They were never followed up They just sit in the notes and never refer to them.

The question is how will the patients understand that the “package of care” is supposed to effect a measured change. It is just Fund Holding by stealth. But what happens when they present for as sore throat separate from this package. You charge!! So what is to stop getting the package and then charging still ?

Again what happens when the patients do not present for their supposed check ups / monitoring. Patients do not care about it all they just want instant health care for free. No responsibility for their actions. To properly manage this you need a database that keeps track of where each patient is up to and what is needed. But do we contact them when they are overdue? No I do not think so. When they come in for a consult (usually unrelated to chronic disease) then you need a quick reference that says that this and this needs to be done. Then do it eg you need cholesterol levels done….

What I as a locum need to do is to make sure that I have solid management plans for the various problems I will encounter. To apply them to various patients at the time of consult eg need BP check / need cholesterols

It is up to the clinics to advise how they want me to manage the new “packages of care” but I suspect that things have gone too far and we will just keep on consulting as we have always done because it will be too expensive to construct an alternative model of consultations using a database of exception reporting.

What then should be done is to just make sure we manage our patients to the best of our ability

Getting at the older doctors !!

Are older GP’s cognitively impaired?  In the Australian Doctor http://www.australiandoctor.com.au/articles/B8/0C05C2B8.asp? the question is raised whether or not older GP’s can practice safely.  It is stated that the public now needs to be protected from the older doctors who may be cognitively impaired.

Actually what has been reported is fact (the Victorian Medical Board) but it is disturbing to see the emphasis that is being put now on “lets see how we can start the process / discussion about older doctors so that they will have to leave by the time the new doctors arrive on the scene (2013).  It will take time to get public opinion settled in this way so that older doctors are viewed with suspicion.

No so long ago we were all encouraged to continue to practice and not retire.  Now it seems that Medicare does not want the extra doctors.  Why?  Because it will cost Mediacre more if they do not restrict supply.  It has been done before with bad outcome from the patients viewpoint but a saving in cost for Medicare.  They gambled on the fact that the resticted numbers of doctors will not push up the price.  Well this worked for the consult fee, but locums can demand much higher fees because of a lack of supply. It will not be long before the average metro practice will push up its fees in order to survive and the patients will have to pay.