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SPECIALISATION in health care has led to fragmentation; we dismember and categorise health care activities at individual, community and national levels. Each age group, from neonatal to aged, has its own set of advocates and practitioners; each organ system, its specific elaboration of techniques and interventions; each major pathology and clinical entity, its own texts and journals, training and awards, meetings, clinics and even hospitals.
The silo, familiar across the Australian landscape for the storage of grain, lends its name to any structure separate and shut off in safe isolation. The word applies appropriately to sites where health care is practised with inward-directed busyness.
We work in silos, increasingly focused on a discrete area of knowledge, expertise and activity. It grows inexorably, encompassed only by allocating more time and attention to its detail.
We know that thoughtful engagement with colleagues or science outside of our personal patch feeds intellectual excitement, spawns new ideas and promotes wisdom, but confined by “keeping up”, we become less open to the broader reaches of medical need and knowledge.
Disintegration infects the structures and processes of care. The agenda at general meetings of the major Royal Colleges erodes into ethical or political concerns; the tyro specialists save registration fees for meetings that address their chosen, choked fields of interest.
Health institutions are thick with bureaucrats whose management expertise addresses bottom lines of finance that relate poorly to the clinician’s concerns. In the face of their apparent dominance, we retreat from organisational involvement into our own small towers of expertise.
Family doctors lack confidence in the range of presentations they confront in primary care; fear of litigation encourages the despatch of a patient to a round of consultant visits. Each allied health profession jealously guards its own status and expertise.
Restoring the balance.is an initiative of the Royal Australasian College of Physicians that recognises the general physician as a threatened species in the profusion of specialist silos. The initiative recognises the difficulty of accessing, in rural areas, the disparate narrow ranges of specialist expertise.
Silos are also an urban phenomenon. In the hospital or the specialist centre, we group with colleagues of like limitation. Opportunities for social exchange and mutual appreciation are few; the doctors’ dining room has disappeared; if there is a coffee bar, we take a cup back to the consulting desk.
Many of the fractures that underlie professional dismemberment in the health system are beyond our control. States control hospitals; the Commonwealth looks after community health and holds the purse strings. Public and private funding of care adds to distance and inequity; for-profit and not-for- profit sectors serve different populations.
Specific areas of discord are receiving attention. Growing numbers of aged persons present with multiple pathologies, and new, sophisticated interventions likely to benefit them continue to appear, seemingly by the month. A plea for closer cooperation between medical oncology and geriatrics has recently been aired.
Frail patients with multiple comorbidities and disabilities that restrict their activities of daily living have poorer outcomes during cancer treatment. They often fail to access the comprehensive attention to frailty, multiple morbidities and psychical issues that geriatric teams embrace.
In other specialist areas also, an intense focus on the specifics of treatment detracts from a broader holistic approach to care.
Don Quixote tilted at windmills, seeing them as ferocious giants. Some of the silos of health care separation and disparity are indeed ferocious giants. Even sustained tilting will not breach them easily; we must focus on what we ourselves might improve.
In our own settings, we might pilot and test new structures and processes that promise to lessen scatter and distance. Health architecture is open to invention. New research centres have been designed with central attractive communal areas that force scientists to meet whenever they move out of their laboratories; that could apply equally to centres where clinicians take their coffee “on the run”. Some family practices offer rooms for specialist sessions that encourage joint consultation and empower general practitioners, while exposing the specialist to basic realities.
The current reluctance of family physicians and geriatricians to attend residential aged care facilities (RACF) or patient homes changes when a general practice is sited within the RACF and continues local care responsibility as a community hub. Nurse practitioners, given more encouragement, remuneration and recognition, and based in the RACF, will be potential key agents for integration of care, moving between hospital, clinic and aged care placement, and linking them all with home care.
Our patients say of the silos “I don’t know who’s looking after me”. They seek seamless, coordinated care and their own personal, competent and available clinician.
That will not happen easily. It is no longer the expected province of the family practitioner, nor will the general physician provide it. The My Health Record offers little assistance until its implementation is accorded a coordinated understanding and commitment across medicine.
We should take the lead in exploring new models of cooperation and communication in the spaces where we practice. Pertinent examples will encourage patients (our best advocates) to press for change in the larger authorities and agencies that, in our grand mixed mess of medicine, have allowed, fostered and funded silo structures.
Emeritus Professor Ian Maddocks is an eminent palliative care specialist, recognised internationally for his work in palliative care, tropical and preventive medicine. He was Senior Australian of the Year in 2013.
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There are many elderly patients with multiple morbidities who are literarily abandoned. Fewer and fewer GPs do house calls, fewer patients have a regular GP that is usually available, specialists stick to their speciality and tell their patient to see a GP for anything outside of their sub-speciality ( and to get a new referral form), public patients ( refer to themselves as second class patients) wait years for an OP appointment. Economics has trumped the sentiments in medical oaths and the hot breath of litigation leads to increasing investigations, referrals and costs. And yet we and the ministers of health and sickness maintain the delusion that we have the best health system in the world.
The General Physician ( I am one, but because you cannot be paid both as a specialist and as a GP-work as a GP) will not make much difference to this situation. Having a caring, competent GP advocate would make a difference. Such a person needs rewarded time and a desire to get rid of the lucrative, quick, low medical value tasks.
As a doctor who treated the indigent I was all in favour of Medibank/Medicare. I never envisaged that it would lead to the detrimental changes that have occurred to much of the ethos of medical practice. The first solution is for the MOH to allow a co-payment Medicare option.
I have been a GP for 38 years, and for many years referred patients to a wonderful general physician. ( He even diagnosed me with acute toxoplasmosis, after I had been quite unwell, and attended an infectious disease specialist, who said there was nothing wrong with me and that the ( relatively few) blood tests I’d had were a waste of tax payer’s money!) The general physician left his practice and went into another area of medicine. There is only one other in the area, who is almost impossible to book in to.
In regards to the care of the elderly, my elderly mum had an acute, life-threatening problem which was handled very well in the local A and E. She lives in aged care and, among other medical issues, has a psychosis which was well controlled, after much trialling of various medications by her psychiatrist. Two months after her discharge, her mental state has deteriorated, and we discovered that the dose of the antipsychotic had been halved and not reinstated.
She is now incontinent as well, as the medication that controlled this for years was also ceased. As she has to see the GP, who has to order the script etc, it takes a week or more to get anything done. He is also not willing to increase the antipsychotic so we must wait for the psych review. She does attend an excellent geriatrician but many of his recommendations are not carried out. I find the situation quite frustrating.
Thanks for this pertinent article. This problem is seen every day in Emergency Medicine in urban hospitals – there is an ever-increasing requirement to admit patients with complex multi-system issues under single-subspecialty teams, who then waste time cross-referring, or, worse, ignoring issues that are not within their areas of interest.
This trend is precisely the opposite of what our increasingly elderly population needs.
“Restoring the Balance” was published more than ten years ago by the RACP and IMSANZ – an interesting document with many laudable objectives, which I read through in full at the time.
I don’t think a follow-up “progress report” has ever been published – possibly because most of the proposals in that document have failed to materialise in any substantive way. Isn’t that the way it always happens?
“a tale told by an idiot, full of sound and fury, signifying nothing” – (Macbeth – William Shakespeare)
Common sense is not common. I’d put you in charge tomorrow.
Hoorray! I applaud your comments. The reduction in general physicians has been a disaster for patients.