twrama 1841_august_2.. - AMA WA

OPINION
bureaucrat decides that, say at least 25-50 per cent of my CHF
patients need to be on a b-blocker at say, at least 50 per cent or
more of the optimal dose (10mg), then I have not ‘performed’.
And what about patient behaviours?
Don and Joan are both DMIIs. Both were diagnosed in
1998 when they weighed 103kg each. Both are now over 110kg.
I have them on optimal doses of oral hypoglycaemics, ACE
inhibitors, CCBs, Statins, Aspirin and more. But while Joan’s
diabetes is fairly indolent (HbA1c remains consistently less
than 6.5 per cent), Don is developing poor control, increasing
albuminuria and every excuse as to why he cannot lose a gram
of weight.
In a chance encounter outside the local supermarket last
year, I saw not one scrap of fresh produce in their trolley; just
high fat, easy-to-prepare products. I have contributed to the
medicalisation of what are lifestyle and choice issues – the very
issues which led to this problem and now perpetuate it.
If PFP demands for example that I check his HbA1c at least
every six months and lipids, every 12-24 months, I may do it
(I do already). But if I am to be held responsible for ensuring
my diabetics achieve HbA1cs below 7 per cent or 7.5 per cent
when I am up against this sort of stuff, then I utterly reject it
– especially if the last or the next study shows worse outcomes
with over-aggressive lowering of glycated Hb.
Furthermore, and proudly, many clinicians began changing
their behaviour long before there were incentives to do so.
Think of the many GPs who computerised their practices, had
practice nurses, instituted care models, recall systems and met
targets just because it was ‘damn good practice’ – there is good
evidence for this including here in Perth.
Additionally, there is potential skewing of practice. There
is already ‘cherry-picking’ of the higher-paying item numbers
in the MBS. If, for example, you care for a large number of
poorly-controlled super-obese diabetics, then a carrot and
stick model could lead to refusal to accept or continuing to
care for the most ‘undesirable’ patients, lest they cause your
stats to look poor. You could cherry-pick the easier stuff and
flick those patients to the public hospitals or other practices,
i.e. lose the very reason we are doctors for fear of losing carrots
and being hit with very large sticks.
Finally, good outcomes can only be achieved with adequate
support, infrastructure and commitment by all – including
patients. And in fact, knowing who your patients are - i.e
patient or practice registration, a discussion in itself. You
cannot optimally manage diabetic patients without access to
all the necessary secondary services. Easy
in Perth maybe, perhaps not in the
Kimberley.
For me, money often
brings out the worst in
human behaviour – we
have already seen the
conflicts that the
changes in Practice
Nurse funding
created. And will this
adversely affect the
very reason we became
doctors or affect the
doctor-patient relationship
as we ‘insist’ patients try
to do things they simply won’t
entertain?
Finally, good
outcomes can only
be achieved with
adequate support,
infrastructure and
commitment by all –
including patients
We must tread carefully. Yesterday’s wisdom is tomorrow’s
folly – remember Helicobacter Pylori and that Judas sold Jesus
out for 30 pieces of silver.
August MEDICUS 19