Tag: advocacy

I’ve had my first complaint

Published on by Sam Heard5 Comments

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?

I want to see a general practitioner

Published on by Sam Heard1 Comment
Cheeky Docs

Cheeky Docs

I am a general practitioner, are you? When a patient says they need or want to see a general practitioner I put my hand up. But so do a lot of other people. Some of those people are better general practitioners than me and some are not so good, but what if the people who are putting their hand up are not general practitioners? Are PGPPP doctors general practitioners? I think not. Do patients know when they are seeing a PGPPP doctor? Almost always. Are GP registrars general practitioners? Not yet. Do patient’s know when they are seeing a GP registrar? Sometimes. What about the other doctors working in general practice?

The situation in general practice is now much like that in hospital. There are many types of doctors at varying levels of experience and qualifications working in general practice. The following types come to mind in order of qualification:

  • International medical graduates that have not passed the clinical AMC (Intern level exam) and working on the basis of exemption from Medicare restrictions
  • Australian graduates doing prevocational experience in general practice who are interns (PGPPP – will cease from Jan 2015)
  • International medical graduates who have the full AMC and working on the basis of exemption from Medicare restrictions
  • Australian graduates doing prevocational experience in general practice who have full registration (PGPPP – will cease from Jan 2015)
  • International medical graduates with full AHPRA registration working on the basis of exemption from Medicare restrictions
  • Doctors training to be a specialist general practitioner or a specialist rural generalist
  • Doctors who have VR based on experience in general practice including grandfathered Australian College of Rural and Remote Medicine Fellows (FACRRM)
  • Doctors who have completed their Fellowship assessment by the RACGP or their Fellowship assessment by ACRRM

The only clearly discernible group of doctors, from the public’s perspective, who have completed and passed an objective assessment by their peers (and so demonstrating that they meet a standard of care necessary to provide a quality general practice service) is doctors with the Fellowship of the Royal Australian College of General Practitioners (FRACGP). There is another small group who have completed formal assessment, the graduates of  ACRRM, but these are not distinguishable from those given the qualification based on experience.

I believe the public has the right to know if they are seeing a specialist general practitioner or rural generalist who has completed formal assessment. I understand that there are many reasons why this is not transparent to the general public, but this needs to change. I suggest that we reserve the name ‘general practitioner’ for those doctors working in primary care who have their FRACGP and ‘rural generalist’ for those who have an assessment based FACRRM (FARGPs could use rural general practitioner?). The reserved name may be “specialist general practitioner” and “specialist rural generalist” if that suits but it needs to be meaningful to the public. Other doctors need to be presented in a way that the public can discern the role and qualifications attained. We can set a deadline for this in 5 or 10 years to give people a chance to be formally assessed, but after that, doctors who have not been formally assessed should not use the reserved name. After all, you cannot call yourself a dermatologist because you work in a dermatology unit; in fact you might well be taken to court.

This may all appear to be in my own self interest; I have the FRACGP and I want to see change. But how on earth do we argue for the value of training in general practice and rural generalism unless the outcome and benefit is available and visible to the people of Australia. Statements like “I will never see a doctor from overseas ever again” or “I just saw a rubbish GP” are increasingly common where I work and unpleasant to respond to. To be fair to all doctors I need to explain to this patient that there is a huge variety of doctors working in general practice and that a blanket statement like this is not appropriate. When the patient asks me how to tell if the doctor is OK, I say, “The only doctor you can be sure of based on their qualification is one with the FRACGP”. Do you have a better idea?

 

Who’s Training in Whose Training?

Published on by Sam Heard1 Comment

WP_20131128_16_12_56_ProI am not sure if everyone is aware of the potential professional crisis for specialist general practitioners if the Department of Health and Ageing decide who is providing training for general practice in 2016. That is the stated aim, presumably not with advice from experts in health care delivery.

The Department contributes public money to primary care and so can decide who has access to what rebates and other financial assistance. This is the case for all specialist training.  During the Howard government a shortage of trained specialist general practitioners developed due to a failed policy to limit health care spending by limiting numbers of doctors. The ensuing GP shortage in outer suburban, rural and remote areas led to the government opening the door for doctors to work in primary care without the qualifications from the RACGP or ACRRM.  These qualifications have been developed to distinguish specialist general practitioners; the FRACGP has never been granted without submitting for the Fellowship exam, or equivalent international qualification. If the value of the FRACGP is not recognised by the community, then value in training to achieve Fellowship is also depleted. This is the crux of the issue and has led to the profession being at a precipice.

We specialist general practitioners understand how to deliver evidence-based sustainable primary health care across the broad range of community settings found in Australia. It is our space, not one invented by governments. Innovations and responses in our profession are not determined in Canberra. We are proud professionals delivering high quality care despite the limits of Medicare. I have worked in the NT for over 20 years and understand the issues with workforce distribution; I am keen to work with anyone who wants to ensure that all Australians have adequate access to primary health care. However the proposed takeover of our training by the Department of Health is unacceptable.

Universities and other large providers will no doubt see this as an opportunity. We will see massive conflicts of interest paying dividends to various agencies to meet workforce needs, fill departmental coffers or bring money to other organisations. Our new registrars have been learning on dolls and out of textbooks for years, and it shows. They want to be able to do doctoring – not be doctors. We have more to do than ever to prepare our registrars for delivery of the services our patients’ need. We need to do better at it.

I have a 7 principle approach to success:

  • The College must determine if placements are suitable for learning specialist general practice
  • The College must determine if supervisors are suitable for training registrars seeking to become specialist general practitioners
  • Our Fellowship must be seen as the hallmark of quality primary care, the doctor with FRACGP as the go to professional to provide primary ongoing medical care and lead the primary care team
  • The College must robustly represent and support our Fellows, particularly our supervisors, and our Members who are working towards Fellowship
  • The College should work hard for all Members to gain Fellowship and all Fellows to improve their standard of practice
  • Doctors with Fellowship should be recognised and promoted as specialist general practitioners and be expected to deliver a higher standard of care
  • The College should be the custodian of knowledge relevant to our professional practice and pathways to providing new and improved services to our communities.

 

The RACGP needs to advocate strongly for our Fellows (especially our Supervisors) and Members seeking Fellowship while working closely with ACRRM and GPRA to ensure that our profession and quality primary health care thrive.

It is our training and those training with us should feel that we are supporting them in their endeavour.

Facing complexity

Published on by Sam HeardLeave a comment

DSC00747

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.