21 August 2018

An open question on access to specialists

General Practice Patients

As I age, I expect my specialist colleagues to age with me, and some to change their working hours, to work part time, or even to retire completely. Retirement may be voluntary or forced upon some specialists, particularly surgeons, and especially for those working in the public sector.

So where does this leave me, and other GPs, who have had a 30 to 40-year relationship with a number of specialists we trust, where we could pick up the phone and expect a consultation within 24 hours, or clinically useful advice given over the phone?

We obviously have to forge relationships with new and younger specialists who belong to a generation far removed from our own.

We are inundated with faxes and brochures from new specialists promoting their skills and training, but we don’t know them personally and have never worked with them, even though these new specialists are often personable and willing to come to the clinic for a lunchtime presentation.

I accept this as a fact of professional life. It is generational change. None of us is here forever. So what have I got to complain about?

My problem is gaining access to these specialist clinicians at a time of real need. I can no longer pick up the phone and expect a friendly voice to respond. I need to email or fax a referral, and in good time the specialist, often a psychiatrist, will arrange to see the patient.

Whereas in the past I would often receive a phone call after the specialist consultation to guide my further management, I am now lucky to get a letter.

Another common response from established, busy, mid-career specialists is: “The earliest appointment is in four months”, or “ I am terribly sorry, doctor has closed his books and is not taking new patients.”

Another problem results from subspecialisation. Let me illustrate. I recently thought I would send a patient with a displaced fracture of the radius and ulna to the local orthopaedic surgeon, only to be informed that “he only takes knees and hips”.

When I asked is there someone else their rooms might recommend, I was told that the only other orthopaedic surgeon “does shoulders”.

Has 10 years of postgraduate training, possibly six or more of those in orthopaedics, omitted the simple skill of reducing a Colles fracture? Or is it that knees, hips and shoulders are more lucrative and Colles fractures can go to the local ED for a registrar to look after?

It seems there is no longer open access to private specialist services. It is as if their clinic is closed, or only accessible for certain problems. In the case of orthopaedics, where is the generalist? And in subspecialisation, try to find one who treats backs!

I recently needed  an appointment for a former police officer who is suffering from PTSD. I spoke to some experts in the field who gave me the name of a psychiatrist who specialises in this area only to discover that he is not taking new patients. His books are closed!

I often wonder what would happen if, as metropolitan GP, I closed my books. Within a matter of days I would be obsolete.

So I was then invited to send a fax directed to a “Dear Doctor @ Intake” and the staff at this large psychiatry clinic would assign the patient to whoever was available.

I presume this will be someone I don’t know who is less busy (I wonder why?) than the consultant who has closed his books.

I believe that I am not the only GP who is experiencing these difficulties. I have often wondered why they arise in specialist practice.

I suspect the answer lies in the nature and structure of private specialist practice. A little like legal practice at the bar, it is a solitary endeavour.

Unlike GPs, who work in teams, specialists have continued to work in isolation and in competition with each other.

Admittedly some orthopaedic groups now do work in teams and cover for each other, but this is not the case for all specialists. As they age, would it not make sense to take a younger colleague into their practice and to promote that colleague to GPs like me so I can utilise the next generation of specialists with confidence?

Large numbers of GPs are working well into their 70s. Procedural specialists less so.

We need to know who is going to take over from our esteemed specialist colleagues and refer with confidence to someone skilled, empathic, available and accessible.

Closing the books is not the answer.

Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years

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2 Comments on "An open question on access to specialists"

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Max Kamien
Max Kamien
7 months 30 days ago
Recently, one of my tennis companions developed a sudden pain and click in his left knee. I diagnosed a tear in the rim of his cartilage. His main concern was the family walking trip in Italy that was booked for three weeks’ time. I organised an MRI for the next day and gave him a referral to a well-regarded knee specialist. My patient was informed that the orthopod would not make an appointment until he had seen the MRI. He would then prioritise my patient according his (the orthopods) interpretation of need. After 3 days, his MRI had still not… Read more »
Louise Stone
Louise Stone
7 months 30 days ago
Couldn’t agree more Leon. I bless my specialist colleagues who can answer a complex question and provide some guidance: may mean I don’t have to refer or if I do, I can make sure the relevant information and investigations are included. But I am very frustrated by certain specialists (especially psychiatry) who reject my referrals with the phrase “this patient is too complex, so I’m not prepared to look after them”. Weirdly enough, it seems I am caring for the most complex cases (especially children with complex psychiatric needs) because I can’t find anyone to see them. It’s like an… Read more »