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.

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.

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 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

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.

Why blog at all??  I think it is important to record my ideas, thoughts and comments as well my forecasts about General Practice.  In this way I can record where I think things are headed.  More importantly what actions I should take to align myself with what I see as the future.  I have done this all my professional life.  It is not second guessing.

But at the moment all I can discern are changes to registration which involves revalidation and comments on cognition tests for doctors. 

There are no changes to basic consulting patterns – no new ideas!!  So what is this telling us.

I believe that Nicola Roxon is just a public servant with a few new ideas but her kite flying evoked the wrong response.  She realises that if allied health is to do any Medicare paid work then there will be an additional cost.  there will be no cost savings.  Also GP’s will not back or support independant groups.  So they function alone and wear the medico-legal challenge.  It is no use thinking that the existing nurses working in doctors rooms will do any additional work.  Their sessions are always full.  There is no more room for any more nurses.

So what would be the result of any mandated changes..eg paid less for driving licenec medicals.  Doctors would still do them and the gap would be more.  Consult pattern will not change. 

Care plans have not altered patient outcomes.  They are done in addition to the normal consultation patterns.  I have written on this before.  So where does all this leave us.  With all this indecision it means that the AMA has got its act together and has formulated solid proposals and highlighted problems.  Now all Nicola can do is to play catch-up.  If she attempts to go against the AMA proposals then her plans will end up in a mess with patients having to pay more.

The major challenge in GP work is to integrate any followup plan in  a normal 15 min consult.  If you attempt to move to a special number then you are monitored  (see what has happened with level C&D consults)

Another challenge is to ensure that we have concise investigation plans for various diseases easily available so we can initiate investigations before referrals.

Nicola is right!!
Her assessment that others can do the job that GP’s do and just as well as the GP is correct.  Sacrilege I know but when you look at what the average suburban GP does each day it is not really that difficult.  When the difficulty level rises then referrals are necessary.
For such a GP the average day is episodic care for people who have aches and pains, feelings of unwellness – all of whom need blood tests, x-rays and ultrasounds all of which will be negative.  Then there are the “check-ups”   BP’s, lipids arthritis etc. Not very complex skill level here needed.  Repeat pill scripts and cervical smears are usually the lot of the female practitioners.  Asthma now needs complex investigations while stable diabetes means more of the same. If changes then off to the diabetic specialist.
PLUS  the forms to complete ranging from Workcover, drivers licence and Centrelink. This is the average day.
There are no emergencies to worry about in the metropolitan area as much we try and fool ourselves to maintain some relevance.  The reality is that serious problems go by ambulance to the A+E dept.  Nursing home visits (if done) are also not complex as the nursing staff do most of the work.
In short if you dare to take on palliative care or manage some cardiac problem then you quick smart get reprimanded by the specialists in those areas.  This is the same for any problem you might have identified.  E.g. prolactinemia or PCOS …off to the specialists.
Why then have we become so dumbed down??
It is a combination of the need for short consults in order to make a decent  living and run a practice – plus the medico-legal implications of mal-management (especially in the metro area)  So we go on saying that only we as GP’s can do it.  Slowly but surely our diagnostic skill levels drop (we do not need them).  We just need a good network of specialists to whom we can refer/. 
We go through the charade of CDM + TCM plans because they generate money, but we know that in order to make a difference follow-up is needed but it can never be properly done.  So on we go as metropolitan GP’s.
As you can see Nicola is right .  it does need a highly trained person to do the job of a metro GP.
This is precisely why you will not get GP’s into rural areas where the skills required are enormous. But no more than used to be demanded of metro GP’s in past times.  We still cling to these outmoded images. Why shift to the country when we can make a living in the metro area without a lot of stress and the deprivations of country life.
All of this is very sad and depressing but this is the way that the govt and social pressures have shaped us.  Most of us keep seeing patients because we like that type of contact and this is why we get upset when Nicola wants us to tackle CDM by a coordinated team approach which means more paperwork and less patient contact.  If we want to be true medical professionals then we should do rural medicine or become a specialist.  This is probably the reason why there is a rise in GP sub-specialisation.
Change is coming. The tidal wave of chronic disease management is here.
So in summary
Until the govt educates the patients about their part in health management we will just keep on being metro GP’s without any high expectations of patient management but avoiding being responsible for the actions of other health professionals around us. It is time to move on when we wake up in the morning and believe what I have just written and believe that what we do will not make the slightest difference to any patient.

Care Plans
Recent discussions have confirmed what I have already written.  I did not mention that another negative is the duplication in entering information in the Plans and the Team Care plans..
I explored the reasons for not wanting to set them up and although I did not specifically mention it, one of the major negatives is the total artificiality of the whole exercise  You go through the exercise of creating a plan and then explaining it.  The patients even sign to say they agree.  But they just see it as a thing the doctor has to do.
They rarely reappear and trying to track for plan adherence is a nightmare.  So the question has to be asked if any plan helps to improve patient care over what is done now without any plans.
The patient appears and you look for what is the chronic disease or diseases they have and then see if they need any follow-up.  Then you arrange it.  It seems to work well but is dependant on the patient coming to see the doctor.  There is no pre-emptive care and this is what care Plans attempt to do.  The whole idea is to construct a planned management approach which should optimise care of any chronic disease.
Follow up could be still done by a receptionist who would do it the same as the ideal followup that should be done for test results / referrals / x-rays .  it would work.  You could say that the patient has been referred for podiatrist.  Have they gone (is there a letter) if not follow it up.  But very labour intensive 
A Professor Georgeff has evolved web based system.  But again it has to be done by staff.  The question is whether or not you are paying a wage just to see if patients look after themselves. Is it worth it??  At the moment no because we are paid for sickness and not patient wellness.  Plans and adherence will be looked at in another light if we are paid on wellness results.  Sounds good but then we focus on adherence and not the patient.

Psychiatric Problems
In trying to understand issues around bipolar disorder it has become apparent that I do not have a solid framework to understand and manage psychiatric problems.
There are many reasons why it is difficult but I will not go into them at this stage.  Treatment options have expanded and there many more medications targeted at specific problems.  I have never been convinced about CBT.  It seems like trying to convince one person by talking to them that they must behave differently.  So this has forced me to distil and put down my ideas.
What has happened is that a person’s behaviour is not appropriate in society and is harmful to themselves. The practice of aberrant behaviour being managed by simply talking worries me.
What has happened?    The patient has made a series of choices to cope with external stresses and their internal responses.  These choices of action are unique to the individual, while many can be grouped as a global response common to many people. But now as society crumbles, as the belief structures of the individual crumble then they no longer are dependant on older belief structures.  Such people have to turn inwards to themselves in order to cope.  Using outside agencies / non-Christian belief groups all disappoint in the end.  So the person has to rely on their own self constructed belief system to cope with life.  So the person tries to cope within this framework and for many the adjustments in response based on this framework hold up.  So people get through the day.
It is when the constructed framework is not able to help, especially when the person has severe destabilising external or self generated stresses trying to cope.  So the framework collapses and in order to preserve themselves they must behave in ways that are not in keeping with the normal behaviour of society.
This is the genesis of mental illness and the form it takes is determined by the person and the constant behavioural responses to various stresses they have made since birth.  All in order to preserve themselves as a person.
Prevention
If from an early age  or even later) people can have a different approach to life.  To cope with the threats / demands made on them. To have an understanding that they are part of the glory of God.  That the Holy Spirit can energize them and they can deal with external threats / pressures in a way that sees God is in control.  No matter what is the problem God always relates with us – in and through the Holy Spirit.  So now they can make better choices of behaviour out of an understanding of God and His world. It is not just about “me trying to cope on my own”.  It is about “me coping using the resources of God and my part in the Kingdom and in worship.”
However sometimes we see people go away from that and revert to their own self belief and actions, with consequent distortions of behaviour often seen.
Some have become too entrenched in their behaviour patterns and change is next to impossible.  In these cases risk / harm management is all that can be done because the torment to the person is very great. Some others go through life crippled but functional – cure is not the word to be used.
So in helping these people.
We should focus on who they are as individuals.  Where are they heading in life?  What is stopping them. We should say that that it is possible to change how you relate to the world and to people.  If you want to change this aberrant behaviour then it is possible by seeing yourself as a caring person concerned with the world outside of themselves.  To see yourself as part of God’s glory of creation, energised by the Holy Spirit. If they chose not to do so, then it is because the behavioural pathways of coping are so entrenched and all we can do is harm / risk minimisation.
Basis of my management
It is out of this framework I approach my patients and manage their mal-adaptive mental mechanisms.  I try to encourage them as individuals.  Sometimes the reversal of such mental mal-adaptions needs the miraculous intervention of the Holy Spirit of God. This in fact is the basis of all conversions.
I realise that I can only half treat the patients who have mental disturbances if I do not attempt to treat them within the dimension of the Christian faith which directly addresses issues of dealing with a guilty conscience.  All through any management approach I must see the person as a child of God, responsible to God and acting in a responsible manner.  This may not be what actually happens but it is the treatment goal to which I should aspire.
 

GP Super Clinics and other GP workforce issues
Just some ideas and thoughts about these issues
14 of the 32 Clinics are going to be in places where GP’s are in reasonable supply.  They have to be established there so as to attract doctors to work in these “super” clinics.  That is where the doctors will come from  These clinics will compete with local GP’s and such GP’s will be forced to join to survive.  That will be a good start to get a group of caring GP’s.
The policy framework of these Clinics will have to lay down After Hours / Home / Nursing Home visits or else there will be a lot of flak.  Probably be in the “tender” documents.  What will happen is that they will charge a lot for such visits or giving it to Locum Services.  There will essentially be no difference to a Corporate set up because the govt will not want to continually prop up such clinics.
Training of GP’s will be part of the set up  and more training $ will be paid to get this going and so lessen the need for smaller clinics to employ such registrars.  These training places will be like the hospitals when they train surgeons / physicians.  Govt money will flow to make sure such training will happen.  If  the clinics appear to be failing then money will flow in to support them.
So the metro market will settle down with these centres focussed on training.
The fact that they will be expected to bulk bill also means that people will tend to go to these clinics.  Also this fits with a report that this is the style of practice the under 25’s want. This episodic approach by patients plus the increasing supply of doctors will downgrade GP work.  Eventually there will be too many metro GP’s.  They will not be driven into the country because 70+% will be female.  Anyway why do rural work with the added rural layer of problems such as Hospital work and emergency work without a lot more money to compensate?.  Why relocate?  Instead niche practices will spring up such as skin , asthma and diabetes.
Even if a 2 year contract offered to relocate to a rural area because then you have to return to what…?   So instead get into a metro practice keep your head down and work 9-5. This might be alright for a female but not a male doctor.  So what will happen.  He will just settle in and do his job and make $.  He will not complain unless there is more money to make. He will develop a life outside medicine such as real estate development or shares.  He will just do the bare minimum in the Practice and chronic disease management will suffer.  He will become self and not practice orientated.  Medicine will just be a job to make money.  He will be very compliant and do whatever the govt wants.  But if it gets very hard he will leave medicine.
This behaviour will be reinforced by the big clinic’s approach to these doctors.
It does not that there will be much interest in chronic disease management unless the clinic organises it.  It is a bleak picture but a realistic one by a group of disaffected professionals unable to move outside defined practice guidelines dictated by governments.
Trebor