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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.

The Royal Australasian College of Physicians at least is suggesting we create “dual-trained” physicians as part of a conservation effort to protect the general physician species. These doctors would have core training in general medicine, in addition to training in a specialty associated with chronic illness — endocrinology or cardiology for example.

The college has warned that “allowing the physician workforce to develop in its current form of narrow specialisation will not address the broad needs of the ageing population and rising rates of chronic disease and co-morbidities”.

And there have also been attempts to roll out a national training program for rural generalists (or GPs with advanced procedural training, depending on your medical politics). The idea is to equip a new generation of GPs with skills in obstetrics, emergency medicine, anaesthetics and surgery after the previous generation was stripped of them through the combined efforts of the specialist colleges and the hospital system.

In the meantime, Mr McGinty and Health Workforce Australia have apparently been doing some demographic number crunching with the aim of listing the actual numbers of GPs, specialists, nurses and various allied health professionals to meet the country’s future needs.

These calculations have been done before – the most infamous example being the 1996 Australian Medical Workforce Advisory Committee conclusion there were 4400 too many GPs in urban areas. A newly elected Howard government ended up capping GP training places to just 400 a year with results that we still live with today.

The HSW numbers are due to be sent to health ministers in March for their consideration. Removing the lid on the agency’s big idea for how to make the changes needed will have to come later.

• After publication of this article in Australian Doctor, Paul Smith received a note from an ophthalmologist suggesting that the case study used in his introduction was wrong in its details: “I suspect your friend had a tear too peripheral to laser with the usual items and instead needed someone with an indirect laser which can get all the way to the periphery.”

But so far as Croakey is concerned, even if the details of the case study are not quite correct, the broader issues are important and worthy of wider consideration.

 

 

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