The difficult challenge of medical indemnity

Published in Australian Medicine 18 November 2019 https://bit.ly/2Dg9ZeL

Healthcare is in danger of becoming humanless

Two communication challenges that have hit the media recently should act as a warning for the increasing automation of communication for GPs.

First, there’s the mandatory new rules for referring patients to public hospital clinics in Victoria; and second, the ineffective management of patients supported by the National Disability Insurance Scheme (NDIS), which sees GPs’ involvement relegated to a form-filling exercise.

Australian Doctor reported last month that Victoria Health had introduced more formality in GPs’ referrals to specialist clinics, including vascular surgery, urology and adult ENT. Patients referred without ‘complete’ information — and the information required is extensive — will no longer be accepted, nor will patients whose referrals do not satisfy specific criteria.

For example, a patient referred for an aortic aneurysm requires radiological evidence that it is at least 4cm in diameter or is growing more than 1cm a year. And a patient for prostate cancer assessment must have a PSA level according to certain age criteria, a palpable prostatic abnormality or bone pain.

These stipulations for referral aim to make the best use of expensive medical care facilities. Sloppy referrals of patients probably not needing specialist attention should be reduced. But care is needed, as with any guideline, to allow clinical judgement to be the final arbiter. No guideline based on statistically grouped data can fit each case.

While guidelines for referral concentrate the mind, they should allow for exceptions based on clinical assessment that need human communication and interaction.

Do we really want to get to a situation where healthcare is as humanless as the likes of border control and modern retail?

Recently in the US, I was impressed (and greatly relieved) to discover that the previous immigration procedures on entry were now paperless, depending instead on facial recognition and fingerprints. But the humans, generally friendly, who had staffed the stalls were also gone.

Arriving at Atlanta, one of the biggest terminals in the country, we also found the coffee shop ominously quiet: orders were placed via an iPad at one’s seat and customers silently consumed refreshments while watching television.

Communications were once based on people speaking to one another rather than completing forms. In US medical circles, there is currently lively controversy and debate about what has been lost with the almost universal move to electronic medical records.

There is evidence of benefit in reducing medication errors, but it is sparse beyond that. Experienced clinicians complain about the opportunity cost of the time spent entering data and the subsequent loss of time for direct patient interaction.

Author John Banville recently reviewed the wide-ranging book The Unnamable Present by Roberto Calosso, an Italian polymath. Writing in the New York Review of Books, Banville quotes Calosso’s concern that, in the brave new world of the web, “information tends to replace not only knowledge, but thought in general”.

The internet leads to “disintermediation” — a loss of connection with others who can help and guide us — and becomes instead a place where “a man can entangle himself in a series of algorithms and imagine he is thinking”. Calosso hopes our preoccupation with digital data “may come to be regarded one day as an instance of mass delirium”.

Why not build into the stylised referral a two-minute (or maybe five-minute) phone conversation between the GP and the clinic to ensure everyone is in sync? This suggestion may provoke mirth because it is naive, but it could be done.

In the case of the NDIS, as with any new system, there will be discomfort. Management of the program in its early years has been unimpressive.

Although GPs fill out a bundle of forms to ensure patients can access the scheme, they’re not deeply involved in the planning of services and have no direct communication with the NDIS when they should have. The issue is now concerning both the AMA and the RACGP.

The tendency of communication based on templates, and information technology, is to reduce the human element and human interaction. This may be vital to the mechanised production of goods, but in the provision of collaborative medical services, it utterly misses the point.

More information: The Unnamable Present by Roberto Calasso, reviewed by John Banville

Published in the Medical Observer 4 November 2019 https://bit.ly/33oXkS4