Category Archives: GP after hours

Avoiding Burnout

An interesting week this week, with several stories coming together for me.

First up, a discussion on doctors.net.uk / ausdoctors.net (the members only service for UK and Australian doctors) on ‘tips for new consultants’. Covered the sort of things that don;t get taught at medical school or in postgraduate training. Also tips on setting up a private practice and avoiding burnout. A common theme was to ‘say no’ to unmanageable workload and to try to take control of the work environment, not let it control you.

Of course all of this is relevant to rural doctors, which leads to the second theme – that of managing workload in the bush. Scott Lewis (procedural GP in Wudinna and newly appointed President of RDASA) rightly points out the constant stream of negativity regarding rural medicine. Despite this, I think Scott and I agree that rural practice really does offer the ‘best bits’ of medicine – a varied and interesting mix, with opportunities to be challenged every day.

Concurrently this week the doctor in Penola, SA has left – citing an unmanageable workload & bureaucratic bungling by Country Health SA. As well as managing a day time clinic, poor chap was on call 24:7 every day of the year and reportedly chastised for having the temerity to be more than 20 mins from the hospital on one occasion (CountryHealth SA contract allows a 40 minute response time). Ironically this doctor was brought in a year or so ago, to replace the previous doctor, who lasted only 4 months.

Of course there’s the local issue on Kangaroo Island, with the sustainable model of Island docs doing 21 out of 28 days per month on call for emergencies, as well as 365 day a year cover for each of obstetric and anaesthetic rosters. This workload was sustainable and allowed respite from the onerous emergency roster, as well as to balance the demands of running a private general practice.

Common themes?

(i) Financial Incentives

Historically money has been thrown to entice doctors to the bush. Whilst this helps, it is ironic that the same incentives are offered to fly-in, fly-out locums who live in the city and cherry pick high-paying locum work. Indeed some rural communities are wising up to this and realising that paying locums $2500 per day is a disincentive to establishment of permanent resident doctors who have to bear practice costs. KI docs got into a stoush with the Health Department (and the ACCC) a few years ago, when asking for more money to provide on call services. The money doesn’t compensate for working day & night – but it does allow one to purchase much-needed locum relief.

(ii) Control of workload

There are 168 hours per week, which I think of rather like a Mars Bar – it should be divided into equal thirds of work, rest & play. An 8 hr working day is sufficient, and allows time for rest (sleep) as well as play (hobbies, other interests – but also mundane things like cooking, eating, toileting etc). Of course most of us experience ‘bracket creep’ with work intruding into time off and eventually life can become 2/3rds work, 1/3rd rest. Not a good idea. Having strict boundaries between work and home life, as well as declining extra duties means that workload is sustainable.

Much better though to share the workload – a roster of several doctors working part-time is a better model than the traditional solo small town GP. Which leads into the third theme..,

(iii) Learning to ‘say no’

Which is the unenviable position the KI docs find themselves in currently. A model hashed out with the Health Department a few years ago allows KI docs to work 21 out of 28 days per month for emergency on call, with the Health Department providing a locum for their hospital on just one week per month. Meanwhile KI docs provided 365 day cover for separate anaesthetic and obstetric rosters. Not a bad effort for six part time doctors, and allows us time off for a break as well as mandatory upskilling.

A proposal that KI docs take full responsibility for the emergency roster and fund any locum relief themselves was met with disappointment, It sets a dangerous precedent – for if the number of doctors on KI were to fall in the future (as is likely), the remaining doctors would be forced into paying for a locum to staff the hospital. A sum of $10,300+GST per week has been suggested as typical locum costs.

Taken to a logical extreme, if the Island doctors were unable to provide the service (through ill health, absence, whatever) they could be liable for a bill of $10,300+GST x 52 weeks … all for the privilege of doing EXTRA work to their usual 9-to-5 private general practice.

This really is the crux of the tension and difficulty in rural practice. Not only are their insufficient doctors and problems with throwing money at all-and-sundry, ultimately we are independent contractors. We already have a job that consumes a standard working week – that of running our own private practice. With that come attendant costs of staffing, utilities, rent etc which must be met.

To ask us to either take time out of practice to work at the State-owned public hospital (for considerably less money) and yet still pay pay own practice expenses seems unfair. And the demands of working extra hours on call takes it’s toll.

In the city, public hospitals are staffed by doctors and nurses working shifts. They are salaried and also get benefits like annual leave, long-service leave and superannuation. In the bush? Doctors work running their own private practices and traditionally have worked ‘on call’. Sadly workloads have increased (particularly in tourism destinations like Kangaroo Island) making on call a significant burden and at the expense not just of doctor’s health, but also ability to service own clinic patients. There is no Super, no annual leave. The Health Dept just wants to staff the roster, but doesn’t really care how this is fulfilled so long as the cost is shifted elsewhere.

Add to this the demands of a Medicare Locals policy that seems to be more about ‘wants’ than ‘needs’ … and the abhorrent policy in South Australia of charging public patients a fee for non-admitted A&E services (contrary to section 19(2) or National healthcare Agreement). It all seems that costs and services are being shifted from State responsibility to private practice.

Hence it is sometimes better to ‘say no’ and do only what you can do.

Any other thoughts on preventing burn out?

Emergencies & GP after hours

Well there’s an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 ‘Telephone triage is not the answer to ED overcrowding’ EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I’m pretty passionate about emergency medicine – sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of ‘access block’ – too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan ‘GP-type’ patients clogging up the ED…but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
and
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients’ admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It’s also relevant to the ongoing issue of what is and what isn’t an emergency – with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as ‘inappropriate GP-type attendances’.

But there is a problem.

Politicians need to be seen to ‘do something’. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn’t work – experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won’t cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good…but that’s only 3% of calls…surely better to spend that money on beds and more clinical staff…not a phone service.

We don’t do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment – because it is a safe approach – history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn’t fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time – but will miss the more unusual or atypical presentations. The UK’s NHS-direct has learnt this, with several lawsuits after missed diagnosis – the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree’s paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment – not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are ‘GP-type’ attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal – but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services – what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers – you need us during working hours for scheduled things like routine maintenance…but we might have to deal with the occasional urgent job like a dripping tap. However you don’t really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I’m a simple chap – I think that primary care generally deals with most things…but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree’s paper establishes that phone triage does not alleviate pressure on EDs – the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there – throwing money at afterhours services by GPs doesn’t really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED – but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

– fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

– fall from a horse with possible cervical spine injury

– four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

– 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

– mental health patient brought in by Police for assessment

– 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say “it is in the political interest of State governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients’

Quite.

What do others think?