I, and many other GPs like me, will do what we think is right. Always have, always will.
Watching my beloved profession be strangled by a number of political agendas and conflicts of interest has been deeply painful over the last five years, but today, I remind myself of something very important.
GPs are intelligent, resourceful, and fiercely loyal to their patients. The good ones (and despite recent coverage, there are a lot of good ones) will not do things that harm their patients.
We have a history in our profession of being deeply effective mavericks. If policies don’t work for our patients, we will work around them. We always have. We’ve worked around PHNs, Medicare, PBS, nudges, CPD requirements, hospital policies and goodness knows what else.
So, here’s what I predict for the majority of GPs who don’t fit the “ideal” model proposed by the health ministers.
There is nothing magic about a co-located multidisciplinary team. If my patient wants to work with a different team that they select, rather than the one in my practice the government thinks is “good for them” I’ll make it happen.
There is nothing magic about having different professional titles on doors in my clinic. I want my patient to have the people they need, not the people the government thinks are “good for them” based on evidence that doesn’t apply to my patient at a given moment in time.
If the practice nurse is the right person, fine. If not, I’ll work around them. After all, there are plenty of ways to co-locate people and not insist on universal teamwork when it’s not in a patient’s best interests.
And if this universal multidisciplinary team was in all patients’ best interests, then all primary care health professionals would need to follow this mandate. But they don’t. Nurses, midwives, allied health practitioners and, of course, pharmacists can use any business model they like to do the work they choose to do.
So I don’t believe the statements that MDTs are universally “good”. They are just “good for GPs” and, in my view, that’s not a good enough reason to mandate them.
If the government insists funding is predicated on presenting data, even when the data is deeply flawed, I’ll work around it. Because quantitative data is rarely valid when it attempts to represent qualitative experience. The data will be presented, but it won’t be good or useful, and it will therefore not drive my clinical behaviour.
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Outcomes will be measured, but in my population, they will not be meaningful, so they won’t be used to drive my clinical behaviour.
I will find my way around compulsory audits that are time-consuming and meaningless, because unlike my non-GP specialist colleagues, I don’t have staff to do the legwork for me, or the IT infrastructure, or the research unit funding, or, to be honest, much data that can be meaningfully analysed in this way.
None of my patients are represented in the trials the “gold standards” are based on. I’ll believe the push to outcomes-based funding when it is applied to something that can be measured meaningfully with numbers. Like hip replacements. Or cataracts. But not the bio-psycho-social complexity I work with.
If I’m required to employ 1:1 GP to other health professionals to access Medicare, I will continue to work in the way we (the patient and I) believe to be right, and I will not fracture their care if it isn’t helpful.
I will co-locate, but I will not mandate teams the patient doesn’t want. Particularly for my patients who are trauma survivors, and need a consistent, longitudinal, single relationship with someone they trust.
I will give you a clean, shiny spreadsheet of numbers if I have to, and I will honestly communicate the numbers I have, but if there is no validity to the measurements, it is to be expected, and it isn’t my problem. I measure outcomes in other ways.
The gold standard has always been best evidence AND clinical opinion AND patient preference. That is patient centred. I will not override that with an algorithm, a nudge, or a policy directive. And if that means I need to find other ways to work around Medicare, it won’t be the first time.
Today I said no to a pharmacist wanting to review my patient’s medications. My patient is in a nursing home and hasn’t changed her meds in a few years. They are optimised. So no, I will not support your lucrative medication review. That’s a few hundred dollars saved for 15 minutes’ work.
Vicarious resistance. The consumer, carer and I against the state.
I don’t like ducking and weaving around barriers to good care, but it’s what we do when confronted by policies that are not in our patients’ best interests. After all, the gold standard is not the average, and it’s not the algorithm. So I won’t follow substandard care that is optimised for patients I will never see.
And I, and many others like me, will do what we think is right. Always have, always will.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
