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GPs and specialists: a dialogue of the deaf?


Ask almost any specialist about their dealings with GPs, and they’re likely to admit that coordination with primary care could be better. And ask any GP about their dealings with specialists, and you may well be on the receiving end of a gripe or two. Melbourne oncologist and Guardian columnist Dr Ranjana Srivastava has recently written that “shared decision-making that involves a specialist and a GP is rare”. She says that for all the talk of teamwork, there’s a lack of communication that has real downsides for the patient. Increasing numbers of patients with chronic comorbidities end up with fragmented care, Dr Srivastava says, with GPs being kept out of the loop due to delayed discharge summaries, and specialists finding it hard to track down busy GPs.

Who’s to blame? According to two large studies, it’s the specialists – if you’re a GP, that is. And of course it’s the GPs, if you’re a specialist. The first study, from the Netherlands, surveyed around 500 doctors – around half of whom were GPs and the rest specialists – about their mutual communications. The vast majority of GPs (85%) thought they were easily accessible by phone. The specialists did not agree: only 32% thought you could easily get a GP on the phone. The specialists were also sniffy about GP referral letters: just 29% of them thought referral letters were generally adequate. Nearly 90% of specialists thought they correctly addressed the issues in the referral letter. Unsurprisingly, the GPs disagreed: only half of them thought specialists adequately addressed the questions.

And did the specialists report back to the GPs in a timely manner? Yes, said 62% of specialists. No, said 78% of GPs. But when they did finally get that specialist report, the GPs overwhelmingly (92%) considered that they followed the specialist’s recommendations. Not so, said the specialists, fewer than half of whom thought the GPs did what was asked of them.

A US study finds similar disagreement between GPs and specialists. This was a considerably larger study involving nearly 50,000 doctors, who were asked about referral and consultations between primary care and specialist physicians. Around 70% of GPs reported that they always or most of the time sent notification of a patient’s history and reason for a referral to a specialist. But there may have been some fibbers among that cohort, as only 35% of specialists said they always or most of the time received such notification. But the imbalance worked both ways: while over 80% of specialists said they always or most of the time sent consultation results to the referring GP, only 62% of GPs agreed that this was the case. Doctors who did not receive timely communications were more likely to report that their ability to provide high-quality care was threatened.

The authors say their study shows the need for “systematic structures, tools and processes for information creation, transfer, receipt, and recognition by the sending and receiving physicians”.

Miscommunication between doctors is widely recognised as one of the main drivers of medical error. The Australian Medical Association has recently published guidelines to improve communications between GPs and other treating doctors. The AMA says specialist outpatient services need to have transparent systems that inform patients and referring doctors of expected wait times for services, and track the priority of referrals.

According to the new guidelines, discharge planning should include telephone, video or face-to-face case conferencing prior to discharge that includes GPs or referring doctors, and a documented plan of care.

“We are delivering very good outcomes for patients in the Australian health system, but we can and should do better. We are confident that the AMA guide will contribute to improved communication and, in turn, better overall care,” AMA President Dr Tony Bartone says.

Has general practice lost its appeal?

Medical graduates are increasingly shunning general practice for specialist disciplines, according to a new report from the Melbourne Institute.

Looking at data from Medicare along with a ten-year study of 10,000 doctors, the report found the number of young doctors taking up general practice has declined in real terms over the past few years.

At the same time, for every junior doctor going into general practice, close to ten are opting for a specialist discipline.

“Money does matter,” says Professor Anthony Scott, who heads up the Health Economics Research Program at the Melbourne Institute lead author of the report.

“Specialists are paid two to three times what most GPs are, and that’s the route junior doctors want to take. Often it is those who can’t become specialists that move into general practice.”

The report also finds GPs are increasingly dissatisfied with their work and job-life balance in their profession.

Job satisfaction fell by 1.5% between 2013 and 2015, reversing a previous upward trend. Coincidentally or not, 2013 is the year the federal government instigated the Medicare rebate freeze.

That freeze also led to a decline in real terms of Medicare revenue per full-time equivalent GP.

However, total GP hourly earnings have increased at double the rate of real wage growth in the economy. The report authors say it’s not clear why, considering the decline in Medicare revenue, but it may be down to practice efficiencies or income from other sources.

And despite the Medicare rebate freeze, the proportion of services that are bulk-billed has continued to climb, with 86% of services in the last quarter of 2016.

The shape of general practice is changing, too, with a decline in the number of GPs owning their own practice. Correspondingly, practice sizes are increasing, with a wider range of services provided by a range of health professionals.

Almost half of GPs worked in a practice with six or more GPs in 2008, climbing to 61% by 2015.

Another striking change in general practice, and indeed in medicine generally, is the rise of the female doctor. In ten years, from 2005 to 2015, the proportion of doctors who were women went up from 33% to 40%. Over 60% of GPs under 35 are now women, which is 11% higher than for specialists.

And yet female GPs earn around 25% less than their male colleagues, even after accounting for the fact that they tend to work fewer hours. Being a mother further penalises women, who earn $30,000 a year less if they have children. By contrast, men with children earn $45,000 more than their childless male peers.

You can read the full report here.

Professor Scott’s views on junior doctors’ motivations for opting for general practice are not necessarily those of doctorportal.