Care for the Community

There is a lack of care of the community. Not only are warm friendly and reassuring doctors more likely to contribute to their patients cures than their more distant colleagues (Lancet 2001; 357;757-762), but also one other study has shown that emergency department patients appeared to attend less often when assigned compassionate rather standard care. Due to the system our patients have very little time to talk about their problems. There are huge waiting times in casualties and when in hospital a patient is subject to dehumanised medicine where they are treated with often technological efficiency without any real humanity. There is very little feedback given to GPs regarding patient care in hospital and this is particularly applicable to private hospitals. Because of the nature of medical training it is difficult for specialists to become involved with the wider social implications of illness for an individual patient.

GPs - The Conductors of the Primary Care Orchestra

GPs, in spite of their enormous role and influence in society, are often alienated individuals who are very conscious of their autonomy and individuality. They are often manipulated by the large medical clinics that they work for. They expect to see seven or more patients per hour with a minute payment for each consultation which after tax is usually about $13 per patient. Often, because they are bulk billed, patients take it as their right that they should see a doctor for what they consider to be a free service and often treat the doctor with disrespect. As consumers, they complain loudly if they are kept waiting or if the GP does not spend enough time with them.

The Failing Health System

Wide-spread dissatisfaction is currently being expressed by doctors not only in Australia but also in the United Kingdom and Netherlands. The British Medical Association recently balloted the UK's 36,000 GPs on proposals for a mass walkout from the NHS. There is a high degree of morbidity within the medical profession through stress and burnout. Associate Professor Peter Schattner has said that the Doctors Mental Health Implementation Committee determined from 1992 - 1997 that the suicide rate for NSW registered doctors was 19.1 per 100,000 - 60% higher than the general population.

Within the context of general practice, there is no easy access to community health services and other primary care services. Doctors rarely get discharge summaries from hospitals. In cases of psychiatric emergencies, and the treatment of drug addicts it is rare that appropriate agencies can be accessed at the time they are needed. There is usually no simplified database referral procedure or even access for other health care agencies. Even with a medical or psychiatric referral it is very difficult for patients to be seen immediately, unless seen privately. GPs rarely get early feedback about patient care from specialists, especially in hospitals.

GP Stresses

Stresses that doctors, particularly GPs are under include

The Under-financing of General Practice

MBS item numbers are the rebates GPs get when they see patients. The Australian Divisions of General Practice in the Consultation Paper on GP financing states that "the problem with the MBS item numbers is that within the context of Medicare these item numbers do not reward quality of practice". This means that the only way a GP can earn a reasonable income when bulk billing is to see at least 6 - 8 patients an hour. The government ensures that a minimum amount of money is spent through the MBS item numbers, and does not reward the quality of care which comes from longer consultations.

GPs - The Gatekeepers

In the health care system, the general practitioners are the gatekeepers, in that they not only make money for themselves by providing service, but also decide what drugs are given, what kind of pathology and investigative procedures are prescribed and to which specialists they refer their patients. The GPs control the patients. The health funds control the money, and the hospitals are the takers of both patients and money. General Practice has become very hard work and the economic return has become much less than it was around twenty five years ago.

Of all professionals in the Australian community, it must be the medical practitioners in general practice who meet the widest variety of people. People of all ages and socio-economic backgrounds see doctors and share with them their personal and physical concerns. It is these facts that make the responsibility of the general practitioner pronounced. When a doctor meets a patient the doctor can hasten or hamper individual and community development.

GPs have a tremendous and wide responsibility towards the healing of the community. If they are to be effective as therapeutic agents they also need to heal themselves so that they can heal others. For many GPs, as well as nurses their status and value in society is diminishing and it is of great importance that they have the self respect and self empowerment to understand the great responsibility they have towards healing in the wider sense. Healing encompasses cultural change as well as change in attitudes. As the generalist specialist the GP has a major role to play.

In some hospitals in New South Wales, there is so much specialization there is no General Physician. GPs have to have a tremendous amount of knowledge encompassing all aspects of medicine as well as very significant and important communication skills.

GPs are in an unenviable situation. The amount of money they are paid in no way compensates for the measure of responsibility towards society. They are generalist specialists with an enormous range of knowledge in all spheres of medicine and yet are not recognized as such.

The System - Funding Drugs and Technology - Not Health

However, people do not realise how distorted and perverted the medical system is. Many patients, accept the status quo and do not realise there is any other form of healing except taking tablets and as long as they can have their cigarettes, drink their alcohol, eat their McDonalds and drink their Coke they are quite happy without realizing that they are programming themselves for progressive degenerative and chronic disease in middle age and later life. The patients have no conception of how to heal themselves. They have no knowledge of good nutrition and supplementation. They are absolutely in the hands of GPs and specialists who are themselves the victims of a biomedical model that forces on them allopathic treatments which over and over again can do them more harm than good. The system does not treat human beings like human beings. It treats them like cattle. The organisations and the bureaucrats that support this system should be condemned for not seeing what is going on and for what should be rightfully humane.

The Ivory Tower of the Specialist Doctor

The problem is confounded by the fact that many specialists do not have any kind of joint consultation with GPs and do not give them the credibility, which is due to them. Some live in their ivory towers, overspecialized and over focused, and do not seem to have an overall approach that GPs have. However, some of our specialists are utterly brilliant and without their dedication involving the art and science of medicine, thousands of patients would be worse off, particularly within the acute sphere of medicine. They are brilliant diagnosticians, scientists, and surgeons. The problem is that these specialists are geared to treating disease which is degenerative and which has already formed. Such diseases as already mentioned are cardiovascular, cancer, arthritic, stroke, diabetic, osteoporotic, and depressive illnesses. They are the final common pathway of a process, which could have been prevented by appropriate nurturing, lifestyle change and nutrition.

Patients are the unwitting pawns in this money game of the medical system. Specialists are so specialized that they are often totally ignorant of the total picture of the patient in terms of nutrition, life situation, and overall morbidity. They rarely link up with other specialists or health professionals to discuss the patient. In terms of discharge from private hospitals, there is often little follow up. In public hospitals, it is rare for GPs to get follow up notes, and joint consultation with the specialist is virtually unheard of. There are usually no specialists available in casualties where only the junior doctors see the first admissions. Specialists come into the picture much later. This is part of the tradition of medicine in Western society.

The Money Game

It is obvious that the health system needs to be more publicly accountable, and it is astounding that although the primary care is the basic gateway for medicine, GPs are not able to have access to proper resources for referral of patients or the ability to plan overall care for their patients including particularly preventive and nutritional care, because they are not reimbursed in this way by the Medicare system.

Corporatisation

It is now coming to a stage where corporatisation is dis-empowering the GP and taking over the role as the arbiter of health to the individual patient. The large corporate bodies know the power of the GP and realise it can be accessed to bring in money through the GPs connection with pathology and imaging facilities, and specialists. The corporate bodies wish to take a controlling interest of these facilities as well as of specialist practices. In this process the GP loses power over the doctor-patient relationship, and the commercial interests intrude between the provision of care by the health professional and the patient.

The Commercial Pressures

The current pressures on the health system in Australia are fundamentally commercial pressures, and the GPs are becoming employees of the corporate bodies. The whole aim of these corporate bodies is to keep costs down and to make profits for their shareholders and themselves. Mayne is not only taking over general practices, but also hospitals, pathology, radiology, pharmaceuticals, and aims to take over health insurance companies. In so doing, they will have enormous political leverage. This vertical integration gives tremendous political power to these corporate bodies .

Profit Vs Healing

Because profit is the bottom line, patients are relegated to being numbers in a share market and the faster and more efficiently the patients are dealt with the happier the shareholders are. In this process, we see the demise of the doctor-patient relationship and the ethos of Hippocratic medicine. We see no understanding of the nature of illness or disease, no understanding of the ability of the patient to heal themselves through mind-body and nutritional approaches, but an emphasis on competition and the survival of the fittest.

The pharmaceutical companies serve to propagate this approach and some of these companies have GDP's greater than countries in the developing world.

The Pros and Cons of Evidence Based Medicine

As so-called evidence medicine continues to progress we continue to see the failures of these trials. Only five percent of evidence based research trials are adequate according to the editor of the British Medical Journal. It is known throughout the world that so called evidence based medicine with pharmaceutical companies is biased and this is why fifty percent of pharmaceutical based research is proven 'adequate'. This conspiracy is funded and enhanced by the government and by the pharmaceutical industry. The International Committee of Medical Journal Editors stated in their joint release on September 13th 2001, that the use of clinical trials primarily for marketing makes a mockery of clinical investigation and are performed to facilitate regulatory approval of a device or drug rather than test a specific novel hypotheses.

Prescription medicine sales have more than trebled in Australia during the past ten years. The annual growth rate is around eight percent and it is expected to average 8.1% over the next five years. The Australian Pharmaceutical Industry turnover was AU$6.9billion in 1999/2000 and prescription medicine sales only were AU$3.7billion in June 2000. Globally the market is expected to expand and reach US $one trillion by 2008

Adverse drug reactions in Australia account for 6 - 7 % of all emergency hospital admissions and up to 22% of emergency admissions of the elderly.

The estimated public hospital cost of drug related admissions in Australia is $350million per year. It occurs in ten to twenty percent of hospital in patients and causes mortality in 0.23% of admissions.

In an article in the New England Journal of Medicine in 1998, by three physicians, it stated that 51% of approved prescription medicines have serious side effects not detected prior to approval.
Evidenced based medicine is the 'in term', but it does not appear to living up to expectations, probably because it is too reductive and deals with statistics and numbers of patients rather than the whole picture or the whole person. We only have to look at the statins and the way they diminish the efficacy of co-enzyme Q10 and can make a patient more prone to cardiovascular disease. The latest research into Cox 2 inhibitors indicates that they may actually increase cardiovascular disease. The introduction of the pill in the 1960's was followed by a large increase of the incidence of breast cancer and still causes many side affects including the suppression of the libido. It is still not known how SSRI antidepressants work. The evidence for the carcinogenic and teratogenic effects of chlorine in our drinking water is still not acceptable by the authorities for obvious reasons. Evidence based medicine is mainly reductive in its approach. It does not see the whole picture. It does not understand that although an allopathic treatment with one drug may work for an organ or a system, it may not work for the whole person.

The Most Scrutinised Profession in the World

In general practice in Australia , GPs are actually in fear of using extended item numbers for longer consultations because they fear being victimized by the Health Commission. If they see more than a certain number of patients a day they will be put before a review committee. This is all because doctors are not allowed to achieve a middle way. and the system is compromised by corporatisation and so-called financial considerations. It is also engineered by the rapid technological and pharmaceutical advances in medicine which have no scope for understanding the person, the psyche or the whole body-mind which makes up a human being. In particular, men do not want to talk about their illnesses. They just want the quick fix. Mothers are so anxious about their babies that they do not realise that it is good for their child to get a fever because it boosts up their immune system so they can fight more illnesses later on in life.

GPs - The Meat in the Sandwich

GPs are the meat in the sandwich. They feel compelled to provide their patients with the drugs and antibiotics that the patients call for and yet cannot give adequate care which requires a preventative, nutritional and lifestyle approach as they are not paid to do this. They thus have to produce band-aid approaches which serve the financial needs of the pharmaceutical companies who wish to promote their latest magic drug. Simultaneously as the most scrutinized profession in the world, they are under the constant watching eyes of the governmental Health Insurance Commission, and the Medical Boards of the various states. Most GPs feel threatened and often victimized by the medical boards which investigate them upon virtually any complaint. In these situations, the GPs are guilty until proved innocent. The principal of one general practice has said that he feels restricted and rendered impotent by the medical board in his state. He says that he has no control over the system and is not adequately represented. He says he has to be very careful how he handles patients to avoid a possible complaint even if this may compromise proper treatment, for example, prescriptions of antibiotics due to the insistence of the patient even though they are not required for a viral infection.

The Health Insurance Commission is a public infrastructure that maintains item and PBS numbers. The government is the prime mover within the health system and leads its initiatives through different agencies which express best practice guidelines for doctors. These agencies comprise groups of specialized doctors.

The government has been planning for ten years to bring public health planning into the field of primary care and are developing incentive practice payments to create standardized protocols for doctors within a wide variety of public health concerns, including diabetes, cervical smears, immunization, asthma and mental health etc. These bodies are also developing complete computerization of the whole of primary medical care so that all patient data and medical records are computerized and can be encrypted through electronic key signatures for transfer to other medical sources. The problem is these agencies do not express the views of the majority of GPs. The protocols that they express have not been discussed with the ordinary GP. They are also based on the biomedical model, particularly biological considerations and do not deal with the psychology of the individual to any great extent or the latest advances in nutritional and mind-body medicine which could save the government billions of dollars through preventative health.

Even though it does not appear this way, the GP is becoming a technician of a supervisory board of specialists couched in the terms of electronic media and accreditation procedures.

The Conspiracy against Healing and Health

There is an absolute lack of public education in medicine. There is a lack of understanding of lifestyle. People no longer know how to live. Making money seems to be taking precedence.

If we wish to create a healing culture, the three requirements are

The support of the community is paramount if we wish to begin to treat people in our society (most of whom end up sooner or later as patients) as human beings. This process requires not only the development of partnerships between the health providers and the community and service coordination but also educating the public in a general understanding of how to take responsibility for their lives and the prevention of illness. We also need to debate what quality of life is. In our society the new religion is economic rationalism and we forget what it is to be a human being. A major change of consciousness is required if we are to survive with quality.

The answer does not lie in drugs alone. It lies in lifestyle, prevention of illness, modification of diet, relaxation and exercise.

It also lies in creating a more surgent, caring and cooperative integrating society which is less alienating and anomic.

ADDENDUM: Contributing Factors to the Demise of the Power of the GP as Conductors of the Primary Care Orchestra

The system is so narrowly focused and self regulating it is unable to see the statistical evidence of burgeoning illness and increased costs because the biomedical model in itself is becoming progressively outmoded and is being taken advantage of to add financial gain to the GDP.

TARGETS FOR THE MEDICAL RENAISSANCE GROUP

It is the general practitioner who should be intimately involved in parameters of health defined by the Ottawa Charter for Health Promotion from which has been derived the World Health Authority objectives Health for All by the Year 2000. This includes; Promotion of healthy lifestyles Prevention of preventable disease Increasing rehabilitation and community health services.