Why bother?

Hong Kong Hang OutIt is easy to get the feeling that we could all do a good job in general practice if it wasn’t for the crazies, the difficult ones, the slower types and the worried well. It is a bit like John Cleese in Fawlty Towers – who made the same mistake.

Today I saw a woman that I met a decade ago. She looked dreadful, much as she had done then. At that time she had been banned from our local emergency department. Now she is unable to get care from the psychiatrists. A decade ago she was complaining of pain and was relentless in trying to get medication and something done. In fact she had an abscess in her neck, no doubt due in some part to her lifestyle. She was sent away to a tertiary center and put through the mill. Spinal surgery, intensive care, rehabilitation.

She recovered in terms of her abscess but remains as out of control now as she was when all this started. Today, 10 years later, she is again begging me not to see her as a drug seeker, a doctor shopper, a write off. It was difficult not to do so all that time ago despite her neurological signs, just as it is now.

I have never prescribed her painkillers or benzodiazepines despite massive protestation: the sort that makes you bleed. It is heart felt, theatrical and even a little endearing before it becomes somewhat intimidating, quickly tedious for those measuring their own responses in terms of best practice or guidelines. There is absolutely no vaguely visible road to success. It is so compelling only because she genuinely suffers so much; wailing, pleading as tissues amass in or near the bin.

She sees her future only in terms of medications provided by doctors; me and my colleagues only in terms of degrees of rejection. She is “The Hulk” of medication users – she even looks a little green. There is no end of medical and social labels that apply, made all the more compelling due to her lack of insight. She is stark naked in her intoxicated disguises.

How to help? Her life is always on a thread. Efforts to help from a myriad of agencies lead nowhere noticeable. The pain is felt by all.

I shook her hand today and we parted peacefully enough. She might take me up on my offer to help her be a little healthier without feeding her hunger for intoxication. Some I have known like her have died younger, some have stumbled into middle age where they sparkle like drunk adolescents in a bowls club. I really wonder at her will to live and be fed. I feel for her family.

Do I have room for hope?

Je suis feminist

Southern Beach Gender is a big topic in medicine at the moment. Since Elizabeth Blackwell (US) graduated in 1849 and Elizabeth Garret Anderson (UK) gained recognition as a Medical Practitioner in 1865, women have been making headway in taking their rightful place in our ‘honourable’ profession. Constance Stone, Australia’s first woman in medicine, graduated in the US in 1888 as the University of Melbourne did not admit women. With hindsight, it appears immensely unfair that women could not study medicine and at what cost to humanity? It has been tough on those leading from the front in what is indisputable social progress. This progress does carry with it implications for our profession and for interactions with our patients and peers.

As our profession becomes more gender-balanced, the status of medicine becomes more dependent on the general status of women in society. Some will know of what happened to the standard and resourcing of the medical profession in eastern block countries when a majority of female practitioners were trained and employed without the status of women changing in those societies. Thus, if we are to be a gender-balanced profession and maintain the status of the profession then we all have an interest in the status of women. Self interest for all!

The majority of patients presenting to general practitioners are female and having access to a greater number of female doctors is positive for those who seek this. Research shows this correlates with the more ‘patient-centered’ approach of female doctors; but as men and women have the same medical training I suspect this is a social skill of women rather than a professional attribute. At the start of my career approximately 40% of women preferred female doctors for PAP tests, 15% preferred men and the rest had no preference. I could find very little data in Pubmed on current preferences but in a recent paper on gender preferences of men with erectile dysfunction it was approximately the inverse. Clearly this varies with cultural influences; importantly the lack of access to a doctor of the preferred gender may lead to reduced uptake of a required service, particularly in non-acute care. This may extend to colonoscopy.

I am aware that modern society is more sexualised and this almost certainly has an impact on gender preference in the consultation. At a Taylor Mac performance I recently attended he described his gender as ‘none’ and his sexual preference as ‘audience member’! Should we ask patients not only their preferred provider gender but also their preferred sexual preference? Would this change things for patients? A heterosexual male patient, whom I have counselled through a distressing period in his life, told me that he would prefer to see another doctor for his check up as he liked me! Presumably this was due to the possibility of an intimate examination. Very young girls with asthma are quite often reluctant to show me their chest when I am examining them. Sexualisation of life further promotes gender alignment in the consultation out of a feeling of safety.

An unintended result of increasing gender alignment is the deskilling of general practitioners in gender-specific medicine. I would propose that this is already a significant problem, added to by an increasing number of doctors working in primary care who are uncomfortable with cross-gender medicine for cultural reasons. Some avoid this aspect of practice altogether. In large cities this is not such an issue but in rural practice it can be catastrophic. The wonderful female doctor visiting program is a patch for this but is not a long term solution as it is very expensive and does not address men’s needs. All doctors need to understand gender and be in touch with those aspects of gendered behaviour that make others feel either comfortable or uncomfortable. General practitioners must take care of humanity, leaving gender preference to their patients.

What are the consequences within the profession itself of becoming gender-balanced? Clearly there are more opportunities for cross-gender interactions with peers; some of these will become sexual. One visible result is the larger number of dual-doctor families rather than the common doctor-nurse couplings of previous generations.  Let’s not get too hung up on people making sexual approaches within the profession even if these are a little foolish or fumbled. When the approach is sexual harassment then there are well established legal pathways. But any association of such liaison with job progression is completely unacceptable – whether through negative threats (“you won’t progress if you don’t”) or positive inducements (“I could do a lot for your career”). Calling this out for what it is should bring the spotlight on the unwanted attention rather than the individual in receipt. Managers must address this, and if the person providing the unwanted attention is the manager, then there must be a third party involved.

Our professional colleges could be a means for this to be dealt with when there is no other mechanism or the system is failing.

We must also consider the possible inappropriate calling of harassment. I am a non-gendered shoulder-touching and kissing sort of person and not everyone finds that acceptable (male and female); but it is my culture and I have got better at recognising when it is not accepted by others. I have never made any sexual advance to anyone at work in my career but I have had one doctor feel uncomfortable with my approach to physical contact. How far can we be expected to change for individuals? It is a general question worth asking. Recognising others’ cultures is important but being genuine and relaxed is also a positive attribute. How far does a widely acceptable non-sexist culture have to take into account another’s culture in these matters? The answer is probably “to reasonable lengths”.

So let’s all be reasonable in most matters but intolerant of any indications that women are being treated in a way that is unfair. This is all about fairness and humanity.

The doctor’s concern is the patient’s fear

River Bed
Katherine River
How often have you listened to a patient’s story and thought, “OMG! This person has a brain tumour.” After a few more minutes listening (if you are into that sort of thing) your concern might have developed into a mere brain abscess or perhaps a cerebral vascular abnormality. Reacting directly to such gut responses is one reason that doctors now do so many CT Scans of peoples’ brains. I am ashamed to admit that we now cause more brain tumours than we detect. That is clearly not good for our patients and the public purse. In fact, it is a disgrace.

So what should we do with this concern that patients so easily generate in our viscera? We ignore it at our peril for we do not know if it is based on reality, searching google and incorporating the symptoms, a grief reaction to the death of a loved one or even just chance. Whatever turns out to be the case, if the patient was not fearful before telling us their story, they will be after they witness our response. 

What I am saying is – the doctor’s concern and the patient’s fear is the same thing. Singular. One. 

 There is a solution. To respond as a professional rather than as a social being. The neighbour, friend or chat room acquaintance will stay with the patient’s fear – “You need a CT Scan my friend”. As a doctor you can feel and acknowledge the concern, either internally or openly with the patient, and recognising that it is probable that the patient is afraid of whatever you have become concerned about. Now park that concern and go about your professional business.  You can continue gently with the history gathering information that might confirm or refute the possible calamity and examine the person carefully. I cannot stress enough the need to examine people carefully if you are going to refute their fear and explain the symptoms another way. The laying on of hands shows care and attention to detail and justifies our professional opinion.

There is still work to do but investigation is not usually helpful if you do not think it will change the management. Investigation may mean an easy life for you and the patient might attend less in the short term. But the patient has proven that they were right to be afraid and shown that the doctor needed to do a test in order to discover that the feared condition was not present. What is that patient to do when the symptom recurs? How long is a reasonable gap before the test is required again as the doctor is unable to allay the fear without the result? It is a bit like the acceptable period before a widow or widower takes a new partner: there is a wide variety of opinion and a lot of gossip.

 Once in a while, the fear may be so out of touch with reality that it is best to refute this in theory and avoid getting dragged into a clinical black hole. I met a patient who was repeatedly terrified that she had melanoma and would only trust a biopsy result; the doctors were concerned. When I refused to do this on the grounds that she had no added risk and normal skin, she became a very frequent attender for a skin check. It was only when we began to focus on the rest of her life that this fear resolved. 

So use your fear barometer, your concern dial, but be aware who is pushing it.

I’ve had my first complaint

DSC00763Yesterday I received the first complaint of my 35 year career through the Health Services Comp
laints Commission. It was submitted on behalf of a patient by my local MP’s office. I spent a few hours yesterday coming to terms with it and again today responding. It has made me realise that we have a problem. I have written to my local MP requesting the chance to spend some time with him to explain the implications of formal complaints through the HSCC after determination of my complaint. I am experienced enough to take this on the chin, but a less experienced doctor will undoubtedly find such a process daunting and is likely to see the community as hostile.

There is no doubt that there is a very great need for a clear and powerful pathway to complain as a citizen about the health care we receive. It is also fundamentally important that this process is geared to deal with complaints at different levels. If the person has been harmed or suffered in a major way, it is important that this goes to APHRA and into a legal process where appropriate. If the person has been harmed in a temporary way, caused to suffer unnecessarily or does not feel that they received adequate care or information, this should lead to a local and careful process. Any claim of offense should be taken very seriously.

However, if the person has been inconvenienced or communication has been poor but has had reasonable care, or the complaint is vexatious, then the professional should not be required to respond in a lengthy manner and should not suffer unduly. If this happens frequently the community will receive more and more defensive care of dubious value. There are already many GPs who largely do what patients request for fear of complaint. Interestingly, a US study has shown that doctors who have very high levels of patient satisfaction have poor outcomes, even in terms of mortality. Patients don’t always know best.

We also need to acknowledge that there are the normal checks and balances that operate in terms of patient experience were no harm results. Patients are free in Australia to seek health care elsewhere or complain to the provider, even publicise the problem (now common on social media). I believe this should be the accepted pathway when no harm has been caused. Accredited general practices have to demonstrate that they act reasonably in such situations and keep a register of complaints.

Such unsatisfactory experiences are universal in all service settings including healthcare settings and some providers and some patients find it difficult at times to understand the situation of the other person. Regulation and heavy handed approaches will not solve this very human situation.

How can we ensure that these increasingly common formal complaint processes do not cause more harm than good? First, a professional who has received a complaint should be able to discuss the complaint with a qualified professional within the complaints environment. This could resolve situations where there are clearly no grounds for complaint and where a conciliatory process is inappropriate. While this might appear to be more costly it would forego the costs to many professionals of the hours spent dealing with a complaint, the demoralising effect of receiving notice from a statutory body and the loss of face with colleagues.

 Second, there needs to be some formal redress for vexatious complaints or minor complaints that have used this heavy handed approach to be heard rather than seeking conciliation through the provider. This requires responsibility of those managing the process to ensure maximum general good and not just meeting the complainant’s wishes. It also requires an apology from the statutory body to professionals when processed complaints are found to be inappropriate or vexatious. Again, while there is no professional input within the complaints environment prior to passing the complaint to the professional this is likely to be frequent.

I fear formal complaints will become all the rage, encouraged by social media and politicians standing up for a fair go. At present the professional has to respond according to legislation – no doubt for our own good. Don’t mistake me, I do believe conciliation is the best approach and practice this avidly in our setting. However, at times it is not helpful to seek conciliation and it is most appropriate to separate and for the patient to seek health care elsewhere. I think a practitioner should have the right to ignore the complaint with the understanding that legal approaches may costly and perhaps not covered by medical defense insurance. Sometimes we know there is absolutely no cause for complaint and absolutely no chance that reconciliation will change anything. What should we do?

Facing complexity

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The wonderful Jan Radford (you should follow her on twitter)  drew my attention to Garth et al’s excellent study on repeat prescription management in general practice. I enjoyed the approach, a  feel good experience. On reflection I think this paper is avoiding complexity and seeing it as a problem for the consumer. Is that fair?

Why do people take medications that are of marginal benefit or doing them harm? Why do so many patients attend and ask for their scripts without any concern for their health and the continuing relevance of these medicines?

My introduction to the study of repeat prescribing was Michael Balint’s excellent research work with a group of GPs entitled “Treatment or Diagnosis: research into repeat prescribing in general practice” published in the 1970s. Although this predates many pharmaceutical treatments for chronic disease, it raises critical issues with regard to human behaviour and receiving medications as a surrogate for care. These are perhaps more relevant today. What does taking the medication mean for that person? Did it start when their mother died, perhaps their child or spouse? Is it the one remaining legacy of a doctor that helped them a great deal and is missed terribly? Does it avoid conversation and inquiry and keep the doctor happy?

A friend told me how he turned up for a script for his epileptic medicine for years after he stopped taking it, just to keep the doctor happy – he was too scared to say he had stopped it. Many people are afraid to stop taking something that affects them negatively for fear of something worse – the wrath of relatives or doctor? The fear of withdrawal effects?

We are the source of repeat prescribing and if we expect people to be organised 99% of the time, then a few people will run short unexpectedly every day. Should we blame them? The amounts vary – 28 or 30 tablets for some things – 25 or 50 tablets for others – 5 or 2 repeats. How do they manage at all? Is the list of medications in their file an “all time list” or an up-to-date managed list. Do you actually know what they are taking?

Then we have the narcotic repeat prescriptions – perhaps 100,000 medical addicts who cannot be late or they feel sick. When will we doctors learn that narcotics do not work for chronic pain, in fact they clearly exacerbate the problem. And Endone should be banned (along with its long acting preparations). What are we doing to people? A pain clinic referral is unlikely to help as the return letters  only seems to justify the damage or at least ease the conscience of the GP.

Finally, we can insist on people waiting for an appointment if they urgently need a script but have been reviewed recently, as a punishment and monetary tactic. This enables the doctor to be seen and the fee to be subsidised or bulk billed.  Is this a reasonable use of public money and is there any measurable benefit?

Repeat prescribing is truly complicated, involving issues of compliance, funding, safety, quality and motivation. Difficulties cannot be seen solely as a problem patients bring on themselves.  The doctor’s statement “Your lack of organisation doesn’t constitute our emergency” could be reflected as “Your complexity, dependency inducement and chaos causes our emergency”. Whatever your point of view, repeat prescribing illustrates the complexity of modern general practice.