Reformation/shift in medical system (1 Viewer)

[cho6092]

Based on anecdotal evidence and my own observations, I feel that nowadays GPs are primarily (of course not always) treating patients either for flu or depression, and just being the first point of contact either to 1) prescribe medication or 2) refer to a specialist. This system is inefficient timewise as well as costwise (imagine how much the govt would have to pay for each consultation).

Even though our health system is probably much better than many other countries, I feel that in consideration of the current deficit and discussions to improve the health system, perhaps a typical clinic/system could move in the direction of having a number of nurses (performing injections, check ups, prescribing medication), working in conjunction with psychiatrists and psychologists at the same workplace, and perhaps a GP specialist or two to make sure that everything is going okay and can attend to special cases (i.e. not flu). This would involve reducing the number of GPs overall (and most probably a significant reduction in medical admissions to university) but increase additional training to nurses to make sure they have sufficient knowledge.

Do you think this kind of system is realistic and could work in Australia?

 

[Havox]

Totally wrong. You need a GP to differentiate the serious from the trivial illnesses and that kind of call is something that can only be trained with years of experience and formal training, ie medical school. If you care to look for the empirical evidence, it actually suggests that the greatest cost saving to the health system is actually greater investment into the primary care sector, meaning the more GPs you have performing preventative healthcare, the better the outcome for the end user (patients) and the fewer cost there is to the system in treating end stage illness.

To answer your question, no not really. It's not realistic. There is a role for community nursing but diagnostics isn't one of them and certainly not prescribing outside of the heavy regulated and highly specialised Nurse Practitioner system.

 

[Schmeag]

There is a nice fable passed around medical circles which explains the role of the GP that you should read at your leisure.

Havoc explains reasons against your suggestion well. As for having specialists such as psychiatrists in-house, this is done in super clinics already.

 

[cho6092]

Totally wrong. You need a GP to differentiate the serious from the trivial illnesses and that kind of call is something that can only be trained with years of experience and formal training, ie medical school. If you care to look for the empirical evidence, it actually suggests that the greatest cost saving to the health system is actually greater investment into the primary care sector, meaning the more GPs you have performing preventative healthcare, the better the outcome for the end user (patients) and the fewer cost there is to the system in treating end stage illness.

To answer your question, no not really. It's not realistic. There is a role for community nursing but diagnostics isn't one of them and certainly not prescribing outside of the heavy regulated and highly specialised Nurse Practitioner system.

Fair point, and yeah, I guess the biggest problem with that would be a much greater potential not to detect serious illnesses from trivial illnesses as you said. Having said that, of course doctors make mistakes here and there but the more training you have the less likely you'll make such mistakes.

I guess what prompted me to bring this up on BOS was because I can't help but noticing more people (especially mid-40s to the elderly) increasingly complaining about their experiences about the lack of quality consultations, "didn't do anything much than refer me to a specialist", "I could easily google this up" etc. etc. Not sure if you and Schmeag agree with this, it seems that there is a gradual sense of distrust and losing respect for health professionals these days; maybe cases like Patel's might have played an influential role in bringing about this general attitude? I don't know, it's just what I feel seems to be the case.

*EDIT* or maybe society is just having higher expectations of doctors and thus get easily disappointed

 

[Schmeag]

Not sure if you and Schmeag agree with this, it seems that there is a gradual sense of distrust and losing respect for health professionals these days; maybe cases like Patel's might have played an influential role in bringing about this general attitude? I don't know, it's just what I feel seems to be the case.

*EDIT* or maybe society is just having higher expectations of doctors and thus get easily disappointed

I think it is a bit of both.

From what I understand, there has been a change in attitudes to healthcare professionals, but over a much longer period of time (ie decades), and due to a lot of different influences. Certainly, increased media coverage of high profile cases such as what you have mentioned or the Bristol scandal have contributed to an extent. This has led to greater oversight and regulation within the health profession (guidelines, protocols, audit...etc.). Economic influences such as increasing state financial constraints, the privatisation and monetisation of health probably contribute to changing patient attitudes and expectations towards doctors. Logistics and available resources play a great part in rationalising patient care beyond the baseline that is patient safety. Privatisation has led to the individual expectation that money can buy health (see above Wizard example), which works against state efforts to improve overall population health, something that GPs play a key role in. However, roles in the healthcare profession are constantly changing, so you are not the first to ask whether nurses or other professionals can perform the roles a doctor has traditionally performed, ie nurse endoscopists. The heart of the matter is how we can minimise costs without jeopardising patient safety. Who knows where healthcare will be at in a century's time?

 

[bangladesh]

Totally wrong. You need a GP to differentiate the serious from the trivial illnesses and that kind of call is something that can only be trained with years of experience and formal training, ie medical school. If you care to look for the empirical evidence, it actually suggests that the greatest cost saving to the health system is actually greater investment into the primary care sector, meaning the more GPs you have performing preventative healthcare, the better the outcome for the end user (patients) and the fewer cost there is to the system in treating end stage illness.

To answer your question, no not really. It's not realistic. There is a role for community nursing but diagnostics isn't one of them and certainly not prescribing outside of the heavy regulated and highly specialised Nurse Practitioner system.

As well as what he mentioned, GPs have a critical role in managing the care of chronic illnesses and keeping them under control. As well as that, a lot of them further subspecialise in something (This mostly occurs in rural areas) and can help in obs/gyn or anastasia for example.

 

[Havox]

I guess what prompted me to bring this up on BOS was because I can't help but noticing more people (especially mid-40s to the elderly) increasingly complaining about their experiences about the lack of quality consultations, "didn't do anything much than refer me to a specialist", "I could easily google this up" etc. etc. Not sure if you and Schmeag agree with this, it seems that there is a gradual sense of distrust and losing respect for health professionals these days; maybe cases like Patel's might have played an influential role in bringing about this general attitude? I don't know, it's just what I feel seems to be the case.

If someone truly knew what to do, they would've Googled it and not gone to see the GP in the first place. A lot of standard treatments for many common conditions aren't particularly complex, that's really no secret in the medical world. The trick is knowing when you do need to do something fancy. "Didn't do much other than refer me to a specialist" is recognising a disease process beyond the skillset of a general practitioner or requiring more specialised investigations that are often unavailable to the GP. That's synthesising a history and examination into a working diagnosis and directing further investigation. No different to asking a radiographer for a CT scan. The above statement is pretty ignorant or at least, an extremely simplistic view of the consultation process.

 

[Medman]

This is my view after starting practice as a doctor. There is a significant number of GPs who are incompetent in certain areas. I work in the ED right now and I've seen quite a few referrals from GPs to the emergency department for trivial illnesses such as upper respiratory tract infection in an otherwise well child (GP did not even examine this patient). After seeing the patient, we would send them home immediately from the ED. Other times I've had GPs refer patients for simply wrong examination findings which even as an intern I could pick up. There are a decent number of good GPs but I feel some GPs don't want to take responsibility for certain issues or perhaps they feel they are out of their comfort zone. This is why there are super clinics as GP specialists can take on cases more suitable to their area of expertise.
From talking to patients. Many patients have very little idea about symptoms and signs. True vertigo vs dizziness, chest pain causes etc. patient's don't understand the pathophysiology and therefore even after googling they may not come to a suitable conclusion.
There is also great variability between doctor's perspectives. I spoke to 3 ED seniors about one patient before and all 3 had differing views on the management. This is especially true for atypical presentations.
Medical school pales in comparison to what you need to know as a doctor. Even as a doctor there is just too much to know holistically and it's a constant battle to stay on top of the latest research and evidence especially as a GP when you are the first point of call.
I think the system works wells but some GPs need to step up their game with regards to when to refer and when not to refer. If patients could go to specialists as a first point of call, patients would only be wasting their money. Chest pain doesn't mean you necessarily mean you see a cardiologist. It could be caused by multiple things if it was lungs (respiratory), malignancy (cardiothoracic surgeon, oncology, respiratory), hernia (general surgeon), angina (cardiology) etc. Also it is sometimes better if the GP makes the initial diagnosis and refers the patient to the right specialists for further management.

 

[Kiraken]

I agree with both Havox on this, it's true that the GP role is vital and that there is absolutely nothing wrong with a referral to a specialist or being checked by a GP for flu in case something is sinister. I don't think that is really a problem at all. Medicine is such a huge field it would be totally impractical for a GP to know absolutely everything and for more problematic issues that require specific knowledge, a GP's role is to identify it and refer to an appropriate specialist, not to treat it all on their own (which could be disastrous without the required experience in that field)

However, Medman also has a point that some GPs are actually *awful* at their jobs and I've encountered some truly dodgy ones both as a patient and a student but i guess this is unavoidable without some sort of auditing process.

 

[Schmeag]

There is a significant number of GPs who are incompetent in certain areas. I work in the ED right now and I've seen quite a few referrals from GPs to the emergency department for trivial illnesses such as upper respiratory tract infection in an otherwise well child (GP did not even examine this patient).

From my own experience, while I can sympathise with the above said plight, I would not agree that a "significant" number of GPs are incompetent. Firstly, working in ED, you only see a minuscule subset of patients that see GPs. While you might recognise a few consistent offenders, most GPs probably do not refer most of the patients that they see. I don't know if anyone has read the linked article I provided above, but this illustrates the point in that it is okay to refer well people to ED, but it is more important not to miss referring sick people to ED. This means that GPs help trim the excess well people from attending the ED, where there is a greater potential to over investigate and over treat. Secondly, as you would probably know (and have even complained about it yourself) patient's histories can sometimes change with each retelling. Thirdly, examination findings evolve. Fourthly, due to aforementioned financial constraints, the GP works in a snapshot timeframe of 15minutes usually doesn't have the luxury of chasing investigations after hours, whereas ED have 4 hrs and access to more investigations. Lastly, a terrible referral letter doesn't necessarily mean a terrible decision. In ED, you can probably relate to getting a lot of referral letters solely consisting of "thank you for seeing X for opinion and management" and a list of out of date comorbidities and medications. This is particularly heinous when the patient can't even tell you why they are there. Communication is key.

It also follows that a large reason for patient dissatisfaction probably lies in miscommunication or lack thereof. Expectation management is an essential non-medical skill doctors need to possess nowadays--you have probably been told that litigation tends to result when patients feel that they have not been listened to or feel that they have been cheated. A 15-minute (or 5-minute) consult allows for quick, succinct assessment, but not necessarily the time to communicate what everything means and why decisions are being made, and potentially can make poor communicators of good doctors.

From talking to patients. Many patients have very little idea about symptoms and signs.

This is an individual thing. Older people may leave everything in your hands and loathe to think about possible causes. Younger people may look conditions up before coming into ED. Some patients will be health professionals who may be great at their jobs, but very difficult patients to handle. Either way, it is important not to put patients down for being health conscious. Rather, it is a doctor's role to been an educator.

Also it is sometimes better if the GP makes the initial diagnosis and refers the patient to the right specialists for further management.

Much like how ED sometimes have no clue about a patient's diagnosis before referring, I would argue that the onus is not necessarily on the GP to diagnose patients first. A GP's role is to be the gatekeeper and decide who is definitely well enough to be managed by the GP alone.

However, Medman also has a point that some GPs are actually *awful* at their jobs and I've encountered some truly dodgy ones both as a patient and a student but i guess this is unavoidable without some sort of auditing process.

That it may well be, but being awful is not a GP or even a doctor-specific problem.

 

[Medman]

From my own experience, while I can sympathise with the above said plight, I would not agree that a "significant" number of GPs are incompetent

I was actually did not mean a significant but I meant a portion of GPs. I was in a rush to work when I typed this so I do apologise. Schmeag does mention a few very good reasons as why GPs may refer otherwise well patients. But the crux of the problem isn’t that. I'm beginning to see and experience it myself, GPs who don't examine patients. I think this is totally unacceptable for almost all presentations but given the 15mins time frame it may be difficult as mentioned above.
Sending well patients to ED is fine but it burdens the already clogged health system. Also if I am able to make a call that the patient is well at my level of training then surely someone with many years experience could easily do the same. Don't forget the fact that certain doctors do not even examine the patient.
Poorly written referral letters do make competent GPs sound absolutely terrible. There is a breakdown of communication and this may lead to the wrong management being implemented. The system should have been set up in a way where all doctors can access each other’s notes, path and imaging results.

Rather, it is a doctor's role to been an educator.

It's hard to educate patients who believe everything they read on the internet. I have educated them but quite a number do not listen. Sometimes it’s almost the same as trying to convince anti-vaccinators and homeopaths.

A GP's role is to be the gatekeeper and decide who is definitely well enough to be managed by the GP alone.

I think the onus is on the GP for diagnosing most patients to prevent them from coming into ED or the hospital. It’s the GP responsibility to refer patients on if they are not sure or medical management can only be completed in the hospital setting.

 

[patpatpat]

Based on anecdotal evidence and my own observations, I feel that nowadays GPs are primarily (of course not always) treating patients either for flu or depression, and just being the first point of contact either to 1) prescribe medication or 2) refer to a specialist. This system is inefficient timewise as well as costwise (imagine how much the govt would have to pay for each consultation).

That is absolutely not true. According to this study of almost 200,000 presentations to Australian GP's, about 2.8% of presentations to a GP involve an URTI (or as you would say, a cold/flu) and 2.6% of presentations involve anxiety/depression. As per the same article, GP's are required to have good knowledge of at least 167 conditions (which can be very broad such as diabetes or cardiovascular disease) in order to properly service their patients.

Even though our health system is probably much better than many other countries, I feel that in consideration of the current deficit and discussions to improve the health system, perhaps a typical clinic/system could move in the direction of having a number of nurses (performing injections, check ups, prescribing medication), working in conjunction with psychiatrists and psychologists at the same workplace, and perhaps a GP specialist or two to make sure that everything is going okay and can attend to special cases (i.e. not flu). This would involve reducing the number of GPs overall (and most probably a significant reduction in medical admissions to university) but increase additional training to nurses to make sure they have sufficient knowledge.

Do you work for the Liberal Party? Because this is the sort of cost cutting bullshit that I would expect from someone who has exactly zero experience with the medical system.

Nurse practitioners have a fantastic role in specialised services where they can receive in depth training in a particular area to the point where they are much more knowledgeable than most junior staff (and some registrars). Introducing them into a primary care field where they do not have the same scientific background, clinical exposure and training in diagnosis and management as doctors do is a recipe for disaster.

That certainly isn't to say that nurses don't have a role in primary care. The best practices I've seen use them to do a lot of IM injections, blood collecting, education of patients on chronic diseases, management, dieting etc. They make practices much more efficient and can undoubtedly improve patient outcomes, and it is a fantastic idea to fund practice nurses to supplement (not replace) GP's.

I guess what prompted me to bring this up on BOS was because I can't help but noticing more people (especially mid-40s to the elderly) increasingly complaining about their experiences about the lack of quality consultations, "didn't do anything much than refer me to a specialist", "I could easily google this up" etc. etc.

Probably because modern medicine is more complex than ever before, and this complexity is increasing every decade. There are certainly dodgey GP's out there who will not even manage the simple conditions and make inappropriate referrals, but if you have a illness with the potential to limit the length or the quality of your life, it is probably better to get input from someone who has specialised in that area, rather than someone who is having to keep up to take in at least 166 other major areas.

 

[Medman]

Nurse practitioners have a fantastic role in specialised services where they can receive in depth training in a particular area to the point where they are much more knowledgeable than most junior staff (and some registrars). Introducing them into a primary care field where they do not have the same scientific background, clinical exposure and training in diagnosis and management as doctors do is a recipe for disaster.

Nurse practitioners are awesome. They take such a huge load off the doctors. In the ED they do cannulas/venepuncture as well which saves a lot of time especially when they send the bloods off before doctors start seeing the patient. After we have seen the patient the blood results are usually back and therefore, we can make better management decisions.

 

[Schmeag]

I was actually did not mean a significant but I meant a portion of GPs. I was in a rush to work when I typed this so I do apologise. Schmeag does mention a few very good reasons as why GPs may refer otherwise well patients. But the crux of the problem isn’t that. I'm beginning to see and experience it myself, GPs who don't examine patients. I think this is totally unacceptable for almost all presentations but given the 15mins time frame it may be difficult as mentioned above.

GPs not examining patients is not a common experience I have had (I would say that I have heard of other doctors from other specialties who have done the same as well). As they say though, history is supposed to be 90% of the diagnosis and examination can occur without laying hands on the patient and should be tailored to the history. In the absence of this reasoning, I agree that it is negligent to not examine a patient at all.

Sending well patients to ED is fine but it burdens the already clogged health system.

The idea is that GPs should try not to miss sick patients more at the expense of sending a patient who turns out to not require the services of an ED. If it is possible to set up a system that reduces said burden on the health system, then great. We have more problems than answers.

The system should have been set up in a way where all doctors can access each other’s notes, path and imaging results.

Would probably help reduce a JMO's workload.

It's hard to educate patients who believe everything they read on the internet. I have educated them but quite a number do not listen. Sometimes it’s almost the same as trying to convince anti-vaccinators and homeopaths.

In ED, half the battle is educating patients about the role of ED--excluding dangerous causes. It is okay to not have a definite diagnosis at the point of departure from ED.

I think the onus is on the GP for diagnosing most patients to prevent them from coming into ED or the hospital. It’s the GP responsibility to refer patients on if they are not sure or medical management can only be completed in the hospital setting.

I agree with the second statement, but not the first. There are plenty of ED bread and butter cases that don't make it to the ward, but still should not be managed in an outpatient setting. For example, I don't believe GPs should be managing chest pain in the clinic by performing serial troponins and ECGs. Therefore in addition to your second statement, I would treat ED as a separate entity to the inpatient hospital.

I find it entirely appropriate to be referred a patient by a GP to rule out dangerous causes. The onus on the GP should not be to diagnose a NSTEMI before sending into ED (it's a bonus for the workload in ED of course).

 

[cho6092]

Do you work for the Liberal Party? Because this is the sort of cost cutting bullshit that I would expect from someone who has exactly zero experience with the medical system.

Nurse practitioners have a fantastic role in specialised services where they can receive in depth training in a particular area to the point where they are much more knowledgeable than most junior staff (and some registrars). Introducing them into a primary care field where they do not have the same scientific background, clinical exposure and training in diagnosis and management as doctors do is a recipe for disaster.

That certainly isn't to say that nurses don't have a role in primary care. The best practices I've seen use them to do a lot of IM injections, blood collecting, education of patients on chronic diseases, management, dieting etc. They make practices much more efficient and can undoubtedly improve patient outcomes, and it is a fantastic idea to fund practice nurses to supplement (not replace) GP's.

I'm sure we all agree that cost-cutting is the last thing we want to hear from any government especially with regards to healthcare, but that does not necessarily mean that we should absolve ourselves from scrutinising and evaluate the efficiency of the current system. As I said before, I think that our country's healthcare system is fantastic in comparison with many other nations around the world, but of course there is room for improvement. As with any industry, there are always limitations with finance and budgets and etc, and we have to be realistic with the decisions that we make. And while health professionals have a duty to provide the best care to their patients, I think it should also be their responsibility to work with the government to suggest how systems and processes within the healthcare system can be improved, INCLUDING budget management. Of course, whether politicians end up listening or not is a different matter.

Which leads to the main point of this thread. As Schmeag said, "The heart of the matter is how we can minimise costs without jeopardising patient safety". I agree with you and Medman that nurses do play a wonderful role in assisting doctors. I'm trying to raise questions like

-should there be a shift towards super-clinics and less individual clinics/private practices, and include more pharmacists/psychiatrists/psychologists
-should we maintain the specialist-gp-nurse roles, or there a place for an intermediary role between the current role of a nurse and a gp, while increasing specialist positions
- etc. etc.
(Some of these have already been discussed in great depth)

And yes, I have exactly zero experience with the medical system, hence raising these questions here on BOS

 

[Medman]

I find it entirely appropriate to be referred a patient by a GP to rule out dangerous causes. The onus on the GP should not be to diagnose a NSTEMI before sending into ED (it's a bonus for the workload in ED of course).

I never said GPs should diagnose all patients. Like I said earlier if medical management is not appropriate in a GP center then yes it should be referred so obviously certain chest pain should be referred to the ED. You are also missing the point that all admissions to hospital go through the ED too and there is no direct admission into the wards unless it's a country hospital where certain GPs have admission rights. ED is part of the hospital system as it has the facilities as an inpatient hospital.

 

[Schmeag]

I never said GPs should diagnose all patients. Like I said earlier if medical management is not appropriate in a GP center then yes it should be referred so obviously certain chest pain should be referred to the ED. You are also missing the point that all admissions to hospital go through the ED too and there is no direct admission into the wards unless it's a country hospital where certain GPs have admission rights. ED is part of the hospital system as it has the facilities as an inpatient hospital.

Sorry, I misread your point which I took to say GPs should diagnose most conditions prior to sending to ED--absolutely my mistake. Nitpicking now, but day patients and transfers are other sources of hospital admissions.

I personally don't mind cho6092's line of questioning. Accusations of conforming to Liberal Party antics and ignorance aren't exactly conducive to the discussion either.