Friday, February 21, 2014

There’s no such thing as minor illness – three scenarios

Where you'd rather be than the doctors... until...

Sometimes commentary about health systems seems to view the people who use them as a nuisance. “If only they wouldn’t come with their minor problems.” “Let’s charge them so they think twice about coming.” We are made to imagine a health systemclogged up with people who shouldn’t be there with all those self-limiting illnesses. Leave the room for those who are properly ill, thank you very much.

It may be surprising to learn that there is no such thing as minor illness. That’s not to say that there’s no such thing as self-limiting illness, but that by trying to keep people out of the health system, we lose opportunities to get them in. Here are three scenarios. 

Scenario 1 – People only walk out with minor illness.

One of the common set of symptoms that people come to the doctor with is things like a cough, sore throat, runny nose, perhaps fevers. It’s really only possible to say this is minor illness at the end of a consultation. These symptoms can be the early symptoms of conditions like meningitis, pneumonia or a septicaemia. Usually they are not, but the headlines make the front page of the newspaper when they are missed. These diseases progress very quickly.
Much of the pressure not to go to the doctor with these symptoms forgets that these are not just an isolated and independent collection of physical occurrences. They are accompanied by feelings – usually worry and anxiety. The decision to come to adoctor is rarely taken lightly. Most people discuss their symptoms with friends and family beforehand and ask for advice on what to do. Some people will consult Dr Google. The decision to see a doctor is driven by anxiety – anxiety for themselves, often anxiety for a child, sometimes anxiety for a partner. (The main exception to this is a request for a medical certificate for time off work – this won’t change while workplaces require certificates for minor illnesses.) People don’t really come in for an antibiotic. That might be the request, but people want their anxiety reduced. That’s why with good listening and careful explanations which get at the reason they are worried, almost everyone is happy not to have antibiotics if they are not required. This is also an opportunity to speak with people face to face about how they make the decision to seek further medical help - probably much more useful than providing written information,

Scenario 2 - …And another thing

About 40% of people bring more than one problem at a time to their GP. (PDF) The minor illness might be a ticket in through the door – the reason they can give the receptionist and their workmates, but there are often more profound concerns that people come with. These might be the chest pain they’ve been having that they’re worried might be serious. Or it might be symptoms of depression or anxiety, or the worry over episodes of hearing voices. Often this is the real problem people come with, but it won’t be raised unless the person feels they can relate to the doctor they are seeing. Sometimes it will come up in the same consultation. All GPs know those final moments in a consultation, with the door about to open, when…”there was just one other thing, doctor.” It doesn’t always happen like this. I am aware that I have had people try me out over something fairly trivial for two, three or more consultations before feeling that I can be trusted enough to tell me about the thing that is really worrying them. If I don’t develop a rapport, I’ll never even know there was something else.
Both scenario 1 and scenario 2 are opportunities for the preventive healthcare that often gets talked about. 85% of the Australian population see a GP each year, which is a lot of opportunity to make sure screening and preventive activities happen, without needing any health check policy. It’s one good reason why we have excellent guidelines about what preventive activities work. And why many of the conceptual models we work with in general practice talk about something akin to “The Doctor’s Agenda” recognising that there are things that the patient needs to be done in a consultation, and there are things the doctor would also like to achieve. 

Scenario 3 - The Perhaps scenario…

Often people do come in with what turns out to be, when they leave, a minor illness. Sometimes these are people who rarely see a doctor at all. They may be young men (who’s consultations are usually shorter, do less preventive activities and deal mainly with physical symptoms) or they may be people whose first language is not English, or they may be people unused to navigating complex health systems, and a bit intimidated by health professionals. Or they may be people who see a range of different doctors. It doesn’t really matter. Everyone at some point is at risk of succumbing to a serious physical or mental illness. If that time comes, people want to see someone they can trust. If, having seen a doctor who treated the person with compassion and respect, and didn’t make them feel like they were wasting their time for something minor, then that will be remembered. And if it is remembered a few months down the line when that breast lump appears, or those suicidal thoughts keep entering the mind unbidden, the question “Who can I turn to?” comes up. One option for the answer should always be “I remember that nice doctor I saw with my cough.”
The seeds are sown in those consultations for minor illness for tougher times ahead, the investment made in the trust that is required to tell of your most worrying, perhaps shameful, secrets when it is required. Most experienced GPs know this, and put time in during those minor illness consultations to develop the trust. General Practice is, after all, a specialty built on relationships over time with patients, rather than a series of one-off information gathering exercises.
There are obviously challenges in funding and workforce. But if we forget that in consultations for minor illness, we are doing so much more than just seeing a collection of trivia, then we are building a health care system which is impersonal, anonymous and foreboding.We don’t just stop people attending their GPs now. We stop them attending in the future, too, perhaps when it really matters.
I should emphasise that this applies particularly to GPs and Primary Care. Emergency Departments are not set up to provide this sort of care, where GPs are. I also include non-medical staff in this description of a GP’s work. Nurses would clearly be involved in developing relationships, too. I am most familiar with the way this plays out for GPs, and know that GPs have been researching and teaching this core part of their role for decades.

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Friday, February 14, 2014

Doctors and the health of asylum seekers

No way should we be treating asylum seekers like this

Like many people in Australia, I am deeply concerned about the way we are treating a vulnerable group of human beings who come to Australia because they are persecuted in their own country.

There are many others who can talk about ways of helping, or our international obligations. My field is health, and I wanted to put in one place what I know from news reports about the health of asylum seekers, and the response of doctors to this.

I want to do this because I am angry, and I think you should be too. Doctors are not known for their left-leaning sympathy, but doctors groups across the political spectrum have spoken out about what is happening already. That's because this is not a left-right political issue, though it's often portrayed as such. This is a human issue. Doctors see every day in their practice the consequences of treating people like this. We are the ones who see and deal, often inadequately, with the problems people have arising from violence in the home, from torture in refugees and from physical and emotional abuse as a child. That our government could be deliberately choosing to do this to people is beyond belief.

Apparently, the biggest single cause of death for detained asylum seekers is suicide. This fact alone should make us ask what we are doing to people. The reports of the effect on children - exhibiting signs of depression - would legally oblige doctors to report the carers for suspected child abuse in any other setting.

Back in December, the Immigration department sacked its Immigration Health Advisory Group, which got a bit of coverage in the press. At the time, we were told that this was because the group was too large, and because they needed advice quickly. Good work from the AAP under a Freedom of Information request shows that the real reason was that it was "difficult for some members to provide health advice independent of their other interests." The minute, written by the secretary of the Immigration Department, goes on to say that these conflicts of interest arose from "natural professional interests and obligations." So that's not conflicts of interest like having a partner who parts owns a lobbying company, or receiving money. That sound to me like the conflict of interest is that they have professional obligations to speak out, to do the right thing! The secretary notes that the policy approaches were contentious, and seems to say that "policy and operational activities are becoming increasingly problematic." (It's possible, though less likely on my reading, that he's actually saying it's the potential and actual conflicts of interest, or the present challenges that are getting more problematic.)

My reading of this is that the Department knew that what they were doing was cruel, and they knew that the professional obligation of the doctors on the health panel would be to speak out, so they sacked them. The former panel member interviewed by the Guardian indicates that the advice the group were giving didn't fit with government policy.

You can see that professional obligation in action in the doctors contracted to work in the facility writing 92 pages of their concerns about the treatment of asylum seekers, and the inadequate systems they were asked to work with to manage this.

You can see professional obligations in action when organisations like the Royal Australian College of Physicians, the Australian Medical Association and the RACGP all speak out against our current policies.

You can see professional obligations in action when Michael Gliksman writes a strongly worded opinion piece for the MJA calling what we are doing torture, and calling on all doctors to speak out against it.

I've come across numerous other doctors speaking out on Twitter and on their blogs about what we are doing.

Why would so many want to sepak out? Why not keep our heads down?

It's because the Immigration Department are right in thinking that doctors can't stay silent on behaviour that harms others. The World Medical Association Declaration of Tokyo is pretty clear on this.

"The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures.
The physician's fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose."
And we can go back to that old Hippocratic maxim understood by doctors the world over, (and even quoted by Tony Abbott)

"Primum non nocere - Above all, do no harm."
If there is one thing we know about the current treatment of asylum seekers arriving by boat, it is that harm is being done. It's why doctors are speaking out both publically and privately.

What you can do