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What to do about the problems caused by super specialisation in medicine?

Among the many competing principles in healthcare delivery and policy are the notions of providing the ‘best possible care for any individual’ versus ‘doing the best for the most at a population level’.

Tied up with this are questions of how to achieve the fairest distribution of healthcare resources, and of health.

On such themes, here is a column, first published in the 10 February edition of Australian Doctor, by the magazine’s political editor, Paul Smith.

It is particularly timely given the current focus on the impact of private health insurance incentives, which, it could be argued, have helped distort health funding towards the procedural end of medicine.

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How to address the problems of medical specialisation?

Paul Smith writes:

I heard this story* in the Australian Doctor office last week. It was about a patient, a GP, who went to see a specialist because of problems with her eye.

During the consult, the specialist confirmed a retinal tear, but he had to refer her to someone else because he was millimetres beyond his scope of practice. Turns out he was a peripheral retinal surgeon, not a central retinal surgeon.

These experiences are not uncommon, although super specialisation and the way it affects the health system is a vexed issue not discussed enough in the public domain.

You could argue that the rise of the specialist common to most health Western health systems will drag them all towards the financially crippling horrors of the US, a country tragically dominated by the sort of people who proudly claim to be experts in the left big toe.

The issue is on the agenda here because the bloke leading Health Workforce Australia, a relatively new bureaucratic colossus with hundreds of millions in its budget balance, has now started talking about the need to resist.

The HWA chair, Jim McGinty, told the AGPN conference in Melbourne last year: “Specialisation has gone too far, driven by the professions and supported by employers … while at the opposite end, the capacity of GPs, generalists and support workers are not being sufficiently valued or managed. We need a broader, and in the cases of general practice and medicine, a deeper scope of practice.”

He went on to say the agency, as part of its job to remould the country’s health workforce, would focus on “rebalancing specialisation and generalism”.

After his declaration I pestered him for an explanation of the sort of policy options available. He seemed to clam up like a crime suspect under police interrogation. It is difficult to know whether this is because he wants to keep the lid on a big idea or because the agency hasn’t started its thinking on the issue.

One solution proposed by the Productivity Commission in its health workforce report back in 2006 was mainly about rebalancing Medicare rebates away from procedural interventions, with greater rewards for consultative medicine.

Whether governments are ready to spend the money on consultative medicine and make the necessary cuts to procedural rebates seems doubtful — especially after the blood spilt when Nicola Roxon went to slash cataract surgery rebates in 2009.

And given the sky-high gap fees patients of super specialists tolerate, you can also argue that only the most extreme fiddling with Medicare would be sufficient to dampen demand for their care. In short Medicare fiddling remains the sort of policy suggestion that leaves politicians, seeing the brickbats coming their way, in a cold sweat – even when the arguments are in its favour.

There are deeper questions. Is it right to interfere with a doctor’s desire to develop expertise and knowledge? In the last analysis, specialisation is about ensuring the most safe and effective application of medical interventions on patients.

Specialisation also grows partly because, in specialist fields, demonstrable expertise and knowledge is the currency that buys status and a career path within the medical profession.

Couple this with patient demand and patient dollars for “medical experts” and you have an environment in which specialisation flourishes. The real significance of all those population-based studies by Barbara Starfield – the late American academic who showed that more medical specialists in your health system (beyond a fixed point) will mean more death — can be lost in the face of the personal forces operating at these individual levels.

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Categories: general practice, health reform, health workforce, quality and safety of health care

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