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IN recent decades, Australian medicine has moved more in the direction of specialisation and subspecialisation. While not talked about much, I believe that this, in itself, has contributed to a maldistribution of workforce. Graduate numbers are high, but many Australians cannot access reliable, affordable care.
Other elements contributing to the medical workforce maldistribution include: a shift towards part-time work and training, poor geographic spread, and variance in career path opportunities and significant income differentials among specialties.
One of the results of these trends has been the growth of multidisciplinary models to balance the fragmentation and extra cost that specialisation and maldistribution bring.
Hudson and colleagues correctly point out that a swing back to generalism would allow a refocusing on the patient rather than just the condition. They also draw attention to laudable steps being taken to promote training in generalism, as well as links between the hospital and community health systems, driven by Local Health Districts (LHDs) and Primary Health Networks (PHNs).
While many specialties refer to “general” and “subspecialist” clinicians, true generalists do not restrict themselves to one set of problems.
Characteristics of true generalists can be summarised as follows:
- take on undifferentiated and unreferred patients;
- both make referrals and accept referrals;
- take on patients of all ages, genders and cultures;
- are person-centred rather than condition-centred;
- are skilled at networking with other disciplines to achieve prompt, effective care of patients;
- are frequently the first point of contact for patients;
- display adaptability, flexibility and resilience in dealing with a broad range of problems; and
- practise a broad range of skills, both manual and cognitive.
A nexus has been reached in Australian generalism. The good work that has been done in training and multidisciplinary work involving allied health now has to be better linked into our hospital systems.
Attempts at creating these links with LHDs and PHNs are still fledgling, so patients and GPs are yet experiencing gaps in care and communication.
The model of care in rural hospitals should act as a basis to rebuild generalism in Australia. It is only by creating a generalist culture and presence within our larger hospitals that the benefits of generalism can be achieved.
Therefore, I propose that larger teaching hospitals once again appoint GPs as visiting medical officers with allocated beds and free admitting rights and rights to consultation liaison work. The GPs would form their own department, have allocated beds and junior doctors. The GPs may also help in the emergency department if needed.
Such a model in larger hospitals will help deal with a number of challenges including:
- lack of genuine generalists;
- costly shifting of the care of patients among disciplines;
- costly overinvestigation and overtreatment of basic problems;
- bed blocks due to reluctance of specialists to admit patients with multiple problems;
- prolonged admissions due to delays in consultations by other specialties; and
- prolonged admissions due to lack of availability of appropriate hospital-based outpatient facilities.
Such a model may also lead to positives for rural generalists:
- better locum pool of skilled generalists;
- ability of rural doctors to gain access to training or career opportunities in cities;
- improved number of post-graduate year doctors entering rural or general practice; and
- boosted confidence of post-graduate year doctors in the practice of hospital medicine resulting in more openness to a rural career.
The benefits of such a model are best highlighted with two examples.
Example 1
A 45-year-old Indigenous woman presents to the emergency department at a major Sydney hospital with shortness of breath, elevated blood sugars and cellulitis.
How it is now
The emergency doctors are frustrated that neither endocrine, nor geriatrics, nor thoracic medicine are willing to admit this patient. The surgeons are in theatre and cannot be contacted; it is unlikely that they will accept the patient anyway. After numerous telephone calls and a 9-hour delay waiting for blood gas results, a computed tomography chest scan and spirometry values, the patient gets admitted to the respiratory ward. Her infective exacerbation of chronic obstructive pulmonary disease is treated, but after 4 days she is still awaiting the endocrinology consultation about her newly diagnosed raised thyroid-stimulating hormone and high sugars. The thoracic team is also awaiting a dermatology consultation to decide whether the cellulitis is indeed cellulitis or something else. After 7 days, the patient goes home with a discharge letter, but is unsure to whom to take this letter, as she has no regular GP. She cannot go back to see any of the doctors who treated her in hospital because she needs to be referred to them.
How it could be
The emergency registrar calls the generalist on call, who accepts the patient without fuss. Within 3 days, she has had her diabetes, thyroid disease, chronic obstructive pulmonary disease and cellulitis stabilised without the need for any outside consultants. When it is discovered that she does not have a regular GP, the admitting doctor agrees to follow her up in the community.
Example 2
A male patient on the urology ward had a transurethral resection of prostate yesterday. He is due to go home tomorrow. On a routine ward check, the nurse discovers that he has an elevated blood pressure of 155/105 mmHg and his blood sugar level is 8.7 mmol/L. She informs the resident who then tells the urology registrar.
How it is now
The urology registrar tells his resident to organise consults from the renal and endocrine teams to assess both problems. Discharge is delayed by 2 days, as the renal team has a backlog of consultations and is further delayed by the renal transplant that happened last night. The patient’s hypertension and blood sugar are both treated with simple, cheap oral medications, and he is told to get referrals from his GP to see the endocrinologist and nephrologists in 3 weeks for follow-up.
How it could be
The duty GP registrar is called. Having done a year of general practice, the registrar realises that both these parameters are not urgent enough to delay discharge, and are probably part of the post-operative recovery process, as the patient is in pain and not mobilising well. The generalist visiting medical officer and registrar advise some lifestyle modifications and some interim adjustments to the patient’s medicines on the spot, and call his GP with advice on how to follow up in the community.
Who will take responsibility for implementing the model? Ultimately, this is a state government domain, so it is for the LHDs to implement.
This model fits in well to rural generalist models already being developed.
What permissions or authorities would be needed? The usual credentialling and medical appointments committees of the relevant LHD. Such would be similar or the same as appointments to rural hospitals.
This model, I believe, will lead to both short and long term savings for LHDs, and should be funded as any other hospital work.
Difficulties and teething problems
Change is often resisted. Hospital administrators may find this model challenging as the role of the GP would not be as easy to compartmentalise and would involve working in all parts of the hospital, as well as the dedicated ward.
Some specialists may resent losing beds or some patients.
Measuring the success of this program
The success of this project needs to be assessed at a number of levels, including but not limited to: cost to the system, satisfaction of hospital GPs, satisfaction of other specialties, registrar satisfaction of training achieved, feedback from nurses and patients, analysis of admission times and patient flow, and casemix analysis.
While great strides are being made in the training and promotion of generalists in primary care, the hospital system is lagging behind in this respect.
Reintroducing general practitioners into the day-to-day workings of larger hospitals will bring cost and cultural benefits that will result in great savings and efficiencies.
More importantly, patient care will shift to more person-focused rather than condition-focused.
Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.
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Anonymous says “as a Respiratory/Sleep Physician, I’m am more aware than most that any cause of tachypnoea will worsen air airflow mechanics and can cause breathlessness in a COPD patient and would want to exclude sepsis and ACS (both of which are more likely in this patient) before subjecting her to any treatments for AECOPD, since escalation of bronchodilator treatment and systemic steroids may in fact do her harm.” The problem is, it’s likely that such a patient has the triumverate of COPD exacerbation, sepsis AND heart failure – as all are frequently co-existant, and linked.
Would you, anonymous Respiratory Physician, happily admit such a person under your own care, and manage all aspects of the shortness of breath, perhaps with some advice, but without needing to transfer care? The problem is that many single-organ-system specialists will not. Some respiratory physicians don’t want to care with people with heart failure, many cardiologists don’t want people with COPD, and the poor patients, with aspects of both, perhaps precipitated by an infection, are caught between the two. Organs in the same body cavity, all connected, yet as distant as planets in some service configurations.
Surely we need to configure the services to fit patient needs, rather than the other way around. We know that there will be more respiratory infections in winter. The fact that an admitting team has admitted 50 patients with exacerbations of COPD does not mean that the 51st patient does not also have COPD – it means that the inpatient services need to use their resources to match, and distribute, demand.
I am “guilty” of being a subspecialty physician ( or at least I feel so after reading the material above). While I agree that we all should be capable of providing care that caters for the entire patient and we should not address solely whatever is identified as the main reason for hospital presentation, reading this article, I find myself alienated. From the perspective of someone who spent my early specialist years taking on locum physician work in rural NSW, sometimes as the only physician in the locale and sometimes covering ICU as well, these days I still would frequently take on the type of patient represented in scenario 1, without the need to routinely consult ID or Endocrinology services. In addition, as a Respiratory/Sleep Physician, I’m am more aware than most that any cause of tachypnoea will worsen air airflow mechanics and can cause breathlessness in a COPD patient and would want to exclude sepsis and ACS (both of which are more likely in this patient) before subjecting her to any treatments for AECOPD, since escalation of bronchodilator treatment and systemic steroids may in fact do her harm. I am playing devil’s advocate here to demonstrate that subspecialty based services can provide high standard care, without extended length of stay. For the record, my primary practice is based in a tertiary public hospital, which does have a strong, well resourced General Medicine service.
All physicians completing training in Australasia do complete 3 years of General Medicine training before embarking on specialist training, and in fact as a panel member for advanced trainee interviews, I have noticed that more trainees are coming through dual trained in General Medicine, which may be a good sign that these trainees recognise the importance of their General Medicine skills.
However, it is simplistic to assume that the scenarios described result from subspecialty based care and unwillingness to traverse the line into other areas of expertise. Every practising clinician has areas of strengths and weakness and this tossing of patients between specialties does sometimes result from a difficulty in ascertaining which inpatient team’s skill mix best matches the needs of the patient. However, often the reason is actually more resource related. It makes no sense to force admit the patient in scenario 1 under the Respiratory Unit if it’s mid winter and the Respiratory Unit has 50 inpatients already, one registrar, one resident and the Endocrinology or ID team have similar workforce resources and only 10 inpatients each.
Sue
When I came back from the US 27 years ago general medicine in Queensland was in trouble – especially in the teaching hospitals. This was because invariably the structure was wrong – ie VMO general physician on 3 sessions per week who had to supervise a busy ward load, admitting every 3 or 4 days and attend at least a couple of outpatient clinics in the same 9 hours per week. In addition they were given the most junior registrars and interns. Impossible to look after the patients properly.
At the same time sub-specialty medicine developed throughout the 70s and 80s and these units were staffed by full-time physicians, had less inpatient load and their junior medical staff were advanced trainees and SHOs. There was no contest. Care was better with the sub-specialty units.
So I suspect the same situation was present in NSW and that gave impetus to remove general medicine from their teaching hospitals. I gather in NSW patients over 65 were/are often sent to Geriatric Medicine units who are unfortunately staffed like a sub-acute service, yet have to deal with sick patients.
When I joined Royal Brisbane & Women’s Hospital 20 years ago the plan was to close general medical units as well.
It was only with the employment of full-time general physicians, (or full-timers plus at least half -time physicians who were committed to general medicine), that Queensland was able to stop the decline in general medical services and prove to the rest of the medical fraternity at our hospitals that we were providing high quality patient care. Currently at RBWH we have 16 advanced trainees in general medicine on our books.
It’s the SODs vs the MODs argument. SODs (Single Organ Doctors) are scared of other organs and will only take fully worked up patients and work in their own labs or units, MODs (Multi Organ Doctors / GPs / General Physicians / Geriatricians and a few others) look at the patient just about anywhere and aren’t scared except when approached by SODs. If we had more MODs and less SODs then patients would get a better holistic approach. SODs should only get referrals when needed for a subspecialty consult or procedure.
Charles Denaro – it’s frustrating that, despite having identified the lack of general medicine in urban NSW teaching hospitals many years ago, there appears to be no trend to return to it. What is driving excessive sub-specialisation in some regions, but not in others?
From where I work in a 300+ bed hospital with multiple subspecialty teams but with thriving general services, the above cases seem very foreign in their management.
In the first case, the patient would be admitted under general medicine with a surgical consult for the cellulitis (or possibly under general surgery with general medical consult). In the second case, general medicine could be consulted regarding hypertension and sugars likely via phone advice, and a diabetic educator would provide lifestyle advice to the patient – none of which would delay discharge significantly.
At my hospital there are multiple general medicine teams so there are a large number of rotations in this for juniors and consultants alike to keep up general skills. The same goes for general surgery which sees a much wider range of presentations than at many more subspecialised hospitals. Many subspecialty areas only work on a consult basis and do not have a bedcard, so patients are admitted under a general team and managed with guidance from the relevant specialty.
It is good for patients to have more holistic care from a consistent team who can manage multiple issues. It is good for teaching and upskilling of doctors in a wide range of medicine. It is good for specialist teams who can focus their time on the complex cases where their expertise is required, as general teams have the skills to manage common admissions.
I agree with the call for generalism, but this can also be done by hospitalists who have chosen hospital medicine as their career and many places still do have this well established.
This is a problem highlighted by the ridiculous system of caring for patients in NSW hospitals. In Queensland (and some other states) we have preserved general medical services run by well trained general physicians who are experienced in the practice of hospital medicine. The examples quoted would come under our service and the patient care is streamlined and cost-effective – even at the Royal Brisbane Hospital.
General Practitioners could look after a subset of patients if they were well trained in hospital medicine. My experience in private hospitals 25 years ago when GPa were allowed admitting rights in Queensland is worrisome. The GPs were too busy to devote the necessary time to look after sick inpatients, they referred patients to me when it was too late, when patients had developed multi-organ failure and when one could look back at the history of the admission to find a litany of wrong decisions and errors.
Frequently what looks and seems simple is more complex. One has to be trained well in this branch of medicine.
Thanks for the article, Aniello. Increasing sub-specialisation is part of our increasingly risk-averse society, where more and more is demanded, with diminishing returns. Paradoxically, patients are becoming more complex while services are becoming more specific. We need to match services to patient needs – not try to shoe-horn patients into a narrow service.
What is it about inpatient teams that basic clinical skills are forgotten? Why can’t inpatient consultants recall the basic principles learned during training, or just call their colleagues for advice?
Apart from routine ED admission decision – which is policy in many institutions but still frequently resisted – we need reform of patient-team “ownership”. Perhaps it’s time to go back to general medical and surgical “on-take” teams, with secondary transfer to sub-specialty teams when essential, and productive collaboration when not. The excuse frequently still given for not wanting to accept ED admission referrals is that the patient might end up under the “wrong team”, and that it is “impossible” to transfer them. So, reduce the need to transfer teams, or make it easier when there is a need. How hard can it be?
It is good to hear constructive interpretations of common situations. When I started reading I thought about the common sense and currency of the topic. Then I started thinking about the limitations of being a generalist GP. While you are good at all the skills listed in the article, it’s a struggle to maintain a whole of patient, clinical existence.
It’s all about process these days. Only some of that comes out of the hospital system; it comes from everywhere – insurance companies, government departments like Centrelink, NGOs funded to keep people dependant in their homes, from patient requests, as well as requirements like accreditation and QI/CPD.
As a generalist GP you are chasing information, providing information or assimilating information, often as an outsider, all the time. The indication is GPs will become increasingly responsible for a (patient-driven) social management system that may evolve to include social welfare and even housing over the next decade. That makes the future of clinical, general practice vulnerable and uncertain. If the system successfully dictates GPs do all that stuff, treating patients will take a back seat and general practice as we know it will be gone forever.
So, as I see it, the author’s ideas are not about GPs taking over hospital turf, but may represent the only future of real general practice. Hospitals may be the only place set up to fund quality, clinical, general practice of 21st century standard.
30 years ago this topic was irrelevant, but generalist, clinical general practice has been squashed by outside influence. It’s an essential part of our profession that has been disrespected and exploited from outside and within the profession.
The author’s ideas are worthy, but it should not have come to this. Doctors would not have allowed our system to get to this point. Trouble is doctors don’t count for much in the battle for money with unskilled medical administration, so I have no confidence our system would consider GPs in this sort of setting – unless just to fill out paperwork.
This is a very sensible idea, which would save a lot of money, time and trouble. We need to move beyond the idea of a patient as a lot of different systems and remember each is one person. Generalist training is very important for students and junior doctors and they should probably do this for longer before entering specialty training. Some hospitals have general physicians, but sadly these are a diminishing number. There are fewer and fewer general medicine rotations available.
Only one problem – there are a lot of people out there at every level protecting their patches, and this extends into accreditation as well as interventions. Besides, would GPs really want to do this sort of post in a hospital? There are not enough of them as it is and finding a GP to even follow up patients can be difficult. Patients do not seem to appreciate the value of long term care and like to doctor-shop. Not sure what the answer is, but as a society we cannot afford the fragmented sub specialty approach. We as caring practitioners need to put our heads together constructively to come up with a solution as things are coming to a crisis in the hospital system. I speak as a physician who has seen the changes over the last 20 years.
Lateral thinking is sometimes the best way to solve curly problems that remain unsolved by conventional methods or approaches. When the problems vary widely and cannot easily be compartmentalised(as exemplified in the cases in this article) to one specialty or clinical pathway it makes great sense to have this lateral option developed further.
Perhaps the concept is similar to a “Hospitalist” as in US, but with the added bonus of the links /interface to primary care sphere. I would support this innovation.
One issue that needs to be addressed is subsequent criticism by the sub specialist when a generalist acts for the patient and initiates treatment while waiting for the consultation. this sometimes can lead to complaints or litigation. If the sub specialist cannot see a patient within a short time frame, he or she should accept that the initiated treatment is to protect or improve patient symptoms and be grateful for the assistance and referral.
Emergency Physicians should have the right to admit patients under the care of the firm that they consider best able to deal with the problem. I remember a confused European lady with acute cholecystitis presenting to the Emergency Department, and the surgeon refusing her because there was no ICU bed available. The Physician refused, as she was a Surgical Problem. I told them that I was admitting her under the Surgeons, but advises a Medical consultation at the same time. By the next morning, the patient was much better because of the antibiotics, prescribed in the Emergency Department. Yes, Generalists are needed, and are to be found in the Emergency Department.
Edward Brentnall