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.
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.
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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