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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.

Does personality drive specialty choice in medicine?

 

One doctor has a dominant personality, is process-driven, brusque with patients and likes to watch rugby when not working. The other is more kindly and empathetic, and takes a real interest in patients’ lives. Can you guess which is the surgeon and which is the GP?

Such doctor stereotypes pervade not just medicine but the general culture itself. Surgeons are bullish and poor communicators; paediatricians are maternal and all smiles; GPs are people persons; pathologists have a morbid fascination with death; radiologists hide out in a dark room. Of course they’re exaggerations – but is it true that certain personalities are associated with certain specialties? Unsurprisingly, there has been some research done on this.

Two Scandinavian studies published this year look at personality traits and speciality choice. One from Sweden involved 400 doctors training for medical specialties, who were assessed for extraversion, agreeableness, conscientiousness, neuroticism and openness to experience.

Doctors training in surgery and general practice did indeed play to type, with lower scores for agreeableness in the former compared with the latter. On the other hand, psychiatrists and hospital service physicians scored lower for conscientiousness compared with surgeons. The study authors speculate that this may be because surgery is dominated by task-based procedural work and organisational skills that require conscientiousness. Psychiatrists, on the other hand, scored highest for openness to experience, which is perhaps linked to intellectual curiosity.

A Finnish study of almost 3000 physicians had some similar findings using the same assessment test of five personality traits. It, too, found that psychiatrists had a greater openness to experience than other specialists, and it also found openness to experience correlated more with working in private practice. Again, agreeableness levels were higher for general practitioners, while surgeons were more conscientious, although they were also more neurotic. Higher levels of extraversion were found in paediatricians and were also associated with a change of specialty.

The authors of both these studies suggest that personality assessment could play a role in medical career counselling and might enhance the person-job fit among doctors.

Another study, this one from the UK, looked at three pathological personality traits – narcissism, Machiavellianism and psychopathy – in 248 healthcare professionals and compared them with a control group of 159 members of the general public. Thankfully for the medical profession, doctors scored lower for these personality traits compared with the controls. But among doctors, surgeons came off the worst, with higher levels of narcissism and primary psychopathy. And in surgery, vascular surgeons were the most narcissistic. The least narcissistic doctors, on the other hand, were geriatricians, cardiologists, GPs and and paediatricians. They were also the ones least likely to show signs of psychopathy – unlike neurologists and vascular surgeons, who were the most likely.

The authors suggest high levels of narcissism in surgery might actually be a good thing, particularly in vascular surgery, where a strong sense of self-assurance and confidence in one’s abilities might be needed to deal with catastrophic emergencies, such as a ruptured abdominal aneurysm.

And finally a couple of studies suggest that doctors in general have a personality profile that doesn’t match that of the general population. A UK study submitted 464 doctors to the Myers-Briggs personality assessment, finding that they differed from the UK adult population on a number of norms. They were more likely to score as introverted rather than extroverted, were more likely to be judgemental in their approach to life management, and in decision-making were more likely to favour objective evidence over personal values.

And a French study of over 1500 GPs found doctors had very different attitudes to health compared with that of their patients. Doctors were more willing to take risks with their health than their patients were. But they were also more cautious with their patients’ health than they were of their own.

You can access the full studies referenced in this article here, here, here, here and here

 

Why it costs so much to see a specialist – and what the government should do about it

Australians pay too much when they go to medical specialists. The government can and should do more to drive prices down. A current Senate Inquiry on out-of-pocket costs will hopefully lead to some policy action.

The problem is clear to anyone who has had to see a specialist recently. About 85% of GP visits are bulk billed, but the rate of bulk billing for visits to a specialist is much lower, at around 30%. The out-of-pocket costs can be very high, hurting patients.

To work out how to reduce the out-of-pocket costs for specialist care, we first need to identify why they are so high. There are four potential reasons.

1. Government rebates?

It may be that rebates for some procedures or for attendances are set too low. Rebates are set by government and may bear no relation to the actual cost of providing a service. Unlike in Canada, there is no obligation in Australia for government to consult with medical practitioners before setting fees.

But this explanation cannot account for the very high variation in fees. If high levels of billing above the nominated fee were due to inadequacies in the fee paid by government, then this would apply to all specialists equally. But in fact, some specialists charge more than others.

2. Supply and demand?

It may be that a specialist’s ability to charge a substantial out-of-pocket premium is simply the result of high demand for a particular service in a particular location.

Certainly, if the market for specialist care was functioning perfectly, supply would adjust to meet demand. But the reality is that specialist care is not a perfect market. Even with the increase in the number of medical graduates in Australia over recent years, there are still shortages of specialists in rural and remote parts of the country.

Here, the government needs to do more. It should consider whether specialists’ productivity can be improved, or whether other health professionals could perform roles in areas of short supply. The Grattan Institute’s 2014 report, Unlocking skills in hospitals: better jobs, more care outlined some options such as nurses performing endoscopies or providing sedation, work mostly now done by medical specialists such as gastro-enterologists.

Left to their own devices, specialists tend to establish their practices in more salubrious, city locations. There’s no guarantee newly accredited specialists will set up shop where their services are needed most. So the government should offer some carrots and wield some sticks to encourage new specialists to practice in rural and remote areas.


Read more:

Why do specialists get paid so much and does something need to be done about it?

How much?! Seeing private specialists often costs more than you bargained for

For real health reform, turn the spotlight on specialists’ fees


Carrots could include subsidies and other support for the first few years in rural or remote practice. Sticks might include restrictions on access to Medicare billing in areas of existing over-supply in particular specialties. This would not preclude specialists establishing practices in over-supplied areas, but rather would limit public subsidies in those areas and thus provide an incentive for newly-minted specialists to go where the need is greatest.

Medicare already provides differential rebates for general practice in different parts of the country (rural and regional compared to inner city). Why not do the same for specialist practice?

3. Market power?

High specialist charges and consequent high out-of-pocket costs may simply be the result of specialists using their market power to maximise their income. Even in areas of reasonable supply, specialists may be able to charge high fees because they benefit from established referral patterns. That is, local GPs, clinics and hospitals may refer patients to particular specialists almost by habit, without paying heed to the fees they change. Patients may not be aware of these fees until they’re committed to being treated by that specialist.

The government could limit rebates in built-up areas already serviced by other specialists.
from www.shutterstock.com

A good way to respond to market power is to strengthen the market, to use competition between specialists to drive prices down. And the first step to improving competition is to increase transparency about prices charged.

The government – and perhaps private health insurers too – should publish information on specialists’ fees: the proportion of visits that are bulk billed, how each specialist’s fees compare to the average of specialists in, say, a 10-kilometre radius, and so on.

The government should further discourage higher fees by eliminating a rebate when fees are significantly above the standard rebate. For example, rebates might be paid only if the specialist fee is less than twice the standard rebate.

4. Skill-based premiums?

The fourth reason there may be high out-of-pocket charges is that some specialists are able to charge a premium for skill – or at least they might claim that is the basis for their high fees. Unfortunately, patients have no way of knowing whether this skill-based premium is warranted.

Again, transparency can help here. Governments and private health insurers should publish information which would help patients and their GPs assess whether a specialist’s outcome-based premium is warranted.

There are, of course, challenges associated with publicly reporting indicators of specialists’ quality of care. Agreement would need to be reached on what the key quality indicators for a range of procedures are in each specialty. Imperfect measures can be gamed, or discourage specialists from treating high-risk patients. And not all differences in performance metrics reflect actual differences in performance.

But opportunities for gaming or over-interpreting performance metrics could largely be removed by reporting performance within broad bands – for example: the bottom 25%, the central half, and the top 25% of performers. In the first instance, reporting should simply state whether, based on the specialist’s record, future performance is likely to be of a high standard.

The ConversationExcessive costs for specialist care hit patients in the hip pocket and can discourage some from seeking appropriate treatment. Driving these costs down would make Australia a fairer and healthier nation.

Stephen Duckett, Director, Health Program, Grattan Institute

This article was originally published on The Conversation. Read the original article.