Archive | June, 2014

Escaping the Medicine of Control

23 Jun


Thirty three years ago, I was attracted to general practice in New Zealand for three main reasons. Firstly, consultations averaged fifteen minutes compared to less than ten in my native UK. Secondly, patients paid a part charge for a consultation, encouraging their active participation in their health. They appeared to be more  motivated, and educated on health matters. And thirdly, and this one attracted me personally, life in general appeared less rushed and the food fresh and more plentiful.

I have continued in general practice ever since with little change to my ‘modus operandi.’ My consultation times have stretched out to half an hour, with well over a full hour assigned to complex issues and new patients. I listen deeply, we share insights, take a history and examine, all to an acoustic background of soft classical music. The overall aim is for us to form a true partnership, gel on our health goals, and for the consultation process to embody the peace and respect so often missing in the person’s life. As well as appropriate and measured prescribing of pharmaceuticals when indicated, and organising tests or referrals, I frequently help the person achieve this state of balance, a physiological coherence, through a few sessions of acupuncture; something I have studied and practised  ever since starting my general practice career.

In recent years I have taught techniques that people can use so that they can achieve such coherence in their own lives. Simple breathing, meditation, emotional freedom techniques and methods to help discover untapped creative abilities.

Over twenty years ago, my wife Trish and myself decided the best environment in which to provide this care was in a purpose built area of our home. Not only could we enjoy it all more, but people coming could feel in some way like guests – with an atmosphere of shared trust ensuing.

Ten years ago we made the decision not to enter into a new direction for general practice in New Zealand. In a radical political  move, doctors were encouraged to become health providers for entities known as  Primary Health Organisations. There were tempting incentives. Patients would be required to ‘enroll’ in a particular practice ( a process known as capitation), and the doctor would then receive a government payment for each enrolled patient, with the idea that the cost to the patient for each consultation would become cheaper. In return for these subsidies, the doctor had certain obligations to community health – the screening of potential chronic ill health, smoking cessation, immunisations etc. These quickly became targeted outcomes that doctor’s practices were required to meet.

Along with these obligations, came paper work, treatment protocols, mandatory software upgrades, and more paper work. ‘Best Practice’ guidelines based on the limits of Evidence Based Medicine were devised and expected to be followed.

The consultation times would be on average fifteen minutes, with a meaningful time of doctor/patient interaction calculated at six minutes.

We wondered just where our little homely practice fitted into this brave new world of primary medical care. So we decided to not sign up and to keep doing what we had set out to do- basically to listen to each person’s individual needs and come up with a plan unique to them that would lead to better health. Financially, we would be worse off – and this has proved to be the case- and patients would have to pay a bit more because of the extra time they were given, and the fact we were not receiving capitation subsidies. We were able to counter-act this somewhat by practising at home and lowering our overheads, we have tried to keep our charges reasonable. Moreover, we decided that our mode of medicine suited us and our patients best, and was mentally, emotionally and spiritually sustainable for use well into our old age.

I also predicted that eventually those doctors entering this PHO could become swamped with bureaucratic duties that lay outside their primary function – to assess, diagnose and heal the person presenting to them. I predicted that in return for government funds, their obligations to the state would increase, and their remuneration for such would decrease. I predicted that the treatment protocols would become more and more prescriptive, with less value placed on clinical judgement honed for years of practice and study.

In short, I predicted many doctors would become unwell, burnt out, dispirited and generally fed up.

I have no doubt that this new wave of general practice has provided certain benefits. Note keeping and simple preventative care initiatives have improved, and basic medical care has become more affordable to those struggling financially( I encourage those seeking my help to keep one foot in this system.)

But on the surface I am not aware of any great improvement to community health. Our poor and poorly educated continue eat unhealthy sugar and fat rich diets, while ‘middle New Zealanders’ – in our lagest city Auckland at least – seem more time-stressed and burdened by debt than ever. My one- day-a-week  work in a university health centre reveals overwhelming numbers of young people carrying the diagnoses of anxiety and depressive disorders.

Moreover, I know of no serious all embracing audit that has evaluated whether this new version of primary health care is an improvement on the past.

In the blogs to follow, I will describe both the joys and the difficulties we have encountered as we strive to continue to practise quality person-centred healthcare. I will show how the gulf between our type of medicine and the type expected from doctors in general is sadly widening; and most importantly what it is that we can all do to help change things for the better.

So thank you for your support. Please bookmark this blog, contribute and reply.

Next blog:  Authentic vs Authoritarian Healthcare.