Drawing a Line in the Sand
In the past, an Australian general practioner did almost all the medical work. He would perfom most surgey. There were surgeons but they were few and generally only in the large cities. There were physicians, but again they were in the large cities. Outside of these areas a GP would remove diseased gallbladders, do emergency Caesarain sections and even do bowel resections. GPs would measure optic pressures, reduce fractures, give immunisations, provide diabetic education, treat diseased toenails, treat heart attacks, treat severe pneumonia, give anaesthetics and deliver babies.
With the increases in population it became possible for communities to support more specialists. As a result there were increasied opportunities to have surgeons, and with time other specilaists, in regional centres. The advent of good transport enabled patients to travel to see specialists. This helped give specialists a sufficiently large patient base to enable viable practices. One might think that this has reduced the scope of general practice. However the vast increase in medical knowledge over the last fifty years hasmeant that GPs are required to know even more than before. In fact GPs are expected to know most things about cardiology, haematology, paediatrics, othopaedic surgery, genetic disorders, endocrine issues and so on. Whilst they may not end up treating Addison's disease, astrocytomas, leukaemia or colon cancer, they need to know enough to suspect the diagnosis, investigate appropriately, refer and assist management. The system works well and provides some of the best health care and most cost-effective health care in the world. It is not a threat to general practice but is an evolutionary process.
A different phenomenon is now becoming apparent. It is not new, but is becoing more obvious. It is the encroachment of non-medical people into the fields normally managed by general practitioners (GPs). Let us examine a few examples:
The Recent Pharmacy Trial.
In 2016, in Victoria, a trial was commenced whereby pharmacists would manage patients under the directive of a care plan written by a GP for such matters as hypertension and diabetetes and INR management. Under this trial pharmacists would monitor INRs via point-of-care testing and adjust the warfarin dose to ensure the INR would be within specified parameters. They could adjust medications as allowed by the care plan in order to achieve a prescribed result. Blood sugars would be measured and diabetic medications adjusted. Advice would be given to the patient in each of these circumstances. The first question to be asked is why? Why should pharmacists be given this role? The justification given is that GPs are too busy and this would lessen their workload. This statement is problematic:
- Are pharmacists working at such a light workload that they can take on this role? Whilst they must exist in small community pharmacies, I have yet to see a pharmacist who was not already working flat out.
- Are general practices really overloaded with work? There is currently probably a surfeit of doctors in Australia.
- Most GPs look forward to seeing a few "simple cases" through their working day. These enable some catch-up with timetables which have run late and some "time-out" from more complex cases.
- Removing these simpler cases shifts the balance to more complex cases. These are not well remuniated and to a degree are cross-subsidised by the simpler cases. Removing the simpler cases adds a further financial burden onto GPs. Many practices are currently struggling financially, paticularly with the Medicare rebate freeze.
- Most practices employ practice nurses to check INRs via POCT. These nurses also check blood pressures and BSLs. Removing some of their work