I’ve just been reading again the Christmas editions - both of the Medical Journal of Australia and Australian Medicine, and apart from the tales at the end, there is much woe and lamentation. It appears we are beset from all sides - from government control to nurse practitioners stealing our role. Not much thought of peace, shepherds or angels, in any guise. How did it come to this?
I’ve just been reading again the Christmas editions - both of the Medical Journal of Australia and Australian Medicine, and apart from the tales at the end, there is much woe and lamentation. It appears we are beset from all sides - from government control to nurse practitioners stealing our role. Not much thought of peace, shepherds or angels, in any guise.
How did it come to this?
I believe we are the architects of our own misfortune.
We were doctors - who used clinical skills and the knowledge of our patients to diagnose and treat appropriately.
We have become technicians, who cannot diagnose without a test, who don’t know our patients, and who practise defensively - protecting our own interests without necessarily putting the patient’s welfare first.
I have met many doctors - through training programs, through working in accident and emergency departments, and in general practice. Most of them have learned helplessness. Some of the overseas trained doctors are the worst, they just wish to stay out of trouble so they order every imaginable test, and if none of them give a diagnosis, they ring the medical/surgical registrar or refer the patient away, depending on their location.
With all the current protocols, guidelines and tests, any reasonable person with a few weeks training could be a doctor in the brave new world.
So where did we go wrong?
We lost the focus on knowing the person and their expectations, and substituted a set of ‘best practice’ guidelines, which enable us to defend ourselves to our peers but have little relevance to the patient, or their life. Best practice is a shifting thing, and evidence bases in many conditions are narrow, both in applicability and effectiveness.
At the ‘top’ of the tree, let’s start with consultants - who are busy, don’t give patients much time, belittle resident staff and give them chores which are ‘. 001 percenters’ (ie not useful in giving perspective). They like to accumulate doctors beneath them with increasingly meaningless jobs, waiting to learn the techniques of that part of medicine. They are ‘partialists’.
Next we have general practitioners, lost in a maze of preventive medicine, rewarded for doing tasks which are less and less relevant, and asked to be the gatekeepers for disabled parking permits, sickness benefits, taxi cards, carer’s allowances (don’t get me going on bloody carer’s allowances- probably the most abused part of our social welfare system), continuation of worker’s compensation certificates, team care arrangements so that the well off middle class can get podiatry, care plans and fitness to drive certificates. At the same time they are trying to fulfil their original role, which was to sort out the people who needed treatment from those who didn’t, and administer at least the simple treatments.
When I teach the students these days, a GP attachment according to the university involves preparing care plans, visiting nursing homes and understanding preventive monitoring. Is it any wonder that they see general practice as boring, until they may grasp the myriad of opportunities which being a GP might involve (most don’t)?
Then we have the young doctors – engaged in a prolonged war to work less hours, increasingly disengaged from the patients, reluctant to actually examine someone. Most would rather order an ultrasound than do a PV exam, and most will order d-dimers on every person with chest pain just to ensure they really get confused.
Next we have universities and their students. With more students there is less patient contact, and while some are attempting to select students with good personal skills and social motivation, others are just selecting students who can afford to pay for their degree. (And while I think Melbourne University’s approach as outlined in the MJA is inequitable, it at least gives local students the chance to do what rich people from overseas have been doing for years.) My last student on attachment didn’t see medicine as a vocation, it was just a “good degree to have”.
If we don’t genuinely re-engage with patients, stressing our professional knowledge and judgment as being superior to what can be found on Google or Wiki, then I think our work may as well be done by technicians and nurses, for we have made ourselves irrelevant.
The turning point may come when the first successful action by a patient against a doctor for ordering unnecessary CT scans (without properly informed consent) and causing a cancer is won. Then, perhaps, we may have to look at going back to the most valuable tools - history, examination and our judgment.
A Christmas without thoughts of the joy of giving, of miracles, of renewal, and of finding a little meaning in our life and work may as well not be celebrated.
It’s now coming up to Easter- what would an Easter Edition have to say?
So come on - let’s see if we can earn the title ‘Doctor’, not just wear it.
Published: 17 Apr 2011