Time to give generalists equal billing

PATIENTS are commonly referred to the emergency department (ED) by their GP and these presentations are occasionally frustrating. Some of the time they have a clear reason for referral and even a letter. At other times, the reason for referral is less clear.

One of my favourite examples is probably the patient who presented, straight from her GP, claiming an abnormal test result that required prompt investigation and treatment. Except with no knowledge of either the type of test or its result. Needless to say, her experience in the ED was as unsatisfying to the patient as it was to the practitioner.

I saw a woman recently who had neck pain and had been referred by her GP with the results of a computed tomography (CT) scan that showed degenerative changes of the cervical spine with possible spinal cord compression.

I can appreciate the reasons behind this referral. Spinal cord compression is nail-biting stuff and not something I’d want to manage in my rooms if I were a GP. We can feel comfortable about managing a presentation like this in the ED of a major hospital where a specialist, a magnetic resonance imaging (MRI) scanner and an operating theatre are just a couple of floors away.

She was elderly and because she presented late in the day she sat in the ED overnight. At some point, she was put in a collar which would have done little to improve her neck pain. She was eventually discussed with a neurosurgical registrar and given that she had no neurological signs and that her CT findings were likely to be chronic, her case wasn’t considered urgent enough to be shoehorned into the next day’s fully booked list for the MRI scanner.

Once this had been communicated to her she left the hospital. None of her problems had been addressed despite her having spent an uncomfortable night in hospital. And while that outcome was frustrating, it’s certainly far from unusual.

I can imagine the GP’s disappointment when she bounced straight back with her problem unsolved.

In metropolitan Australia we have the luxury of being able to escalate a decision to the ED, the specialist, the super-specialist, and for patients at the margins of survival, the intensive care unit. We delegate decision-making to a higher power because we’re all confined within the limits of our scope of practice and we fear the consequences should we step outside it.

As a result, we all learn, whether we’re junior doctors, GPs, ED physicians or specialists, to make ineffective decisions or not to make them at all. Our health care system sometimes seems to prefer us to make no decisions rather than to make many good ones at the risk of getting one of those decisions wrong.

The expectation that a complex patient can only be managed by a certain specialist comes at a cost that often falls on patients themselves. My elderly patient met it by spending a miserable night in a scarce hospital bed.

It’s a familiar tale. It could be avoided if we acknowledged that there are many instances where asserting the authority of a generalist doctor to make decisions would benefit both our patients and our health care system.

In the context of an ageing population this change feels inevitable anyway. There simply aren’t enough specialists, and nor will there ever be, to tend to all of our ageing bodies. Referrals will necessarily be curbed and generalists will fill the gaps that specialists no longer can.

To some of our patients this change will be welcome. My generation of doctors, already struggling to secure vocational training positions, will be forced to embrace it. The ascendancy of the specialist physician has dominated the medical narrative in recent memory. It’s time we gave their generalist colleagues equal billing.

Dr James Dando is an intern at a major Sydney hospital.

 

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