Australia’s new health minister, Sussan Ley, is in the midst of consultations on a range of healthcare issues, including a “co-payment” on Medicare. She has already rebranded it from a “price signal” to a “value signal” – but how do we judge value? A recent experience made me realise some home truths regarding that very question.
Some time ago, my mother, a relatively well woman in her 60s, told me that she had a headache associated with dizziness and imbalance. She couldn’t lift her head off the pillow. It turned out that she had suffered the symptoms for some days before she thought of telling me. Now, she looked unwell and uncomfortable and my mind began to search furiously for a cause.
My mother speaks English well enough but like many patients, including those for whom it is a first language, her vocabulary is ill equipped with medical terminology. So the descriptors she used included feeling funny, shivery, odd, and just not right, all sincere phrases from a patient’s perspective that do little to define a diagnosis.
As I sat with her, my thoughts turned to people like her whom I regularly care for. As an oncologist, I will see a fraction of such patients harbour a brain tumour – although the symptoms have usually been present for longer than a few days.
During my stint as an internal medicine physician, similar patients will turn out to have a specific kind of stroke called a posterior circulation stroke, which can require prolonged rehabilitation. Sometimes, patients who present like my mother turn out to have meningitis or encephalitis, both with significant long-term implications.
It was late in the afternoon and I quickly calculated the logistics of sending her to hospital. She didn’t require an ambulance and if I were to drive her, my children would need care.
Undecided, I sought advice from an emergency physician. I already knew that she would endure a long wait because although she felt terrible, her vitals were stable. He said that it was likely that based on her symptoms he would need to admit her for a workup. It was easy to fill in the gaps from there, as she would end up on a general medicine unit similar to mine.
I worried that my mother would be apprehensive, self-conscious, affected by a lack of sleep and the unavoidable din of a hospital in action. Anxious about getting her history just right for the throng of doctors rising above her, the strength of her story would soon diminish, causing the scans and tests to skyrocket in search of an answer.
An IV, a full blood panel and a CT scan of her brain would be just the start. If the CT scan were clear and her dizziness persisted, the doctors wouldn’t be able to rule out subtle cerebral pathology and she would join the queue for an MRI. In the several days it can take to obtain an MRI, she would wait in bed, advised by the nurse to not walk without supervision. Her doctors would fly past, waiting for the conclusive MRI. The MRI would most likely be normal although there was a distinct chance that she may not improve much, or even feel worse from the lack of rest.
The more I thought about it, the less appealing hospitalisation seemed. Yet, as I pondered which serious condition afflicted my mother, I felt an urge to get her the help she needed. It was then that my husband, an experienced GP, walked in. He turned to my mother and asked her four questions after which he said four words:
“Well, you have vertigo.”
My eyes widened. Really? Just vertigo and not some major diagnostic dilemma requiring the combined intellect of multiple sub-specialists? How could he be so sure? I mean, he had been untying his shoelaces while taking a history! “I have seen this so many times,” he said, shrugging. I felt even more foolish when he gave her an over the counter antihistamine combination and she felt better within the hour, after which she checked in with her own GP who similarly reassured her.
Here I was, the specialist physician, entertaining the worst possible explanations and lining her up for thousands of dollars of tests on the public purse and a GP had fixed her with four pointed questions and a tablet worth a few cents.
This wasn’t even the six-minute medicine we hear our politicians decry. This was more like 60-second medicine! Wouldn’t you say that the outcome was vastly preferable to the alternative, for the individual patient and the healthcare system?
Besides the obvious conclusion – that a doctor cannot treat a parent objectively – there is something else I’d like to observe.
This isn’t a tale about good or bad doctors (or prodigal and prudent ones) but an illustration that all doctors view patients through the prism of their experience. When presented with a set of symptoms, specialists immediately think of serious diagnoses because this is what they frequently see. Most dizzy patients under my care are seriously ill, so my mind is trained to consider those possibilities first, and work my way down to benign causes. For me, benign positional vertigo is a diagnosis of exclusion.
A paediatric oncologist bemoans that every headache his son describes smells like a brain tumour to him, until his pragmatic wife rolls her eyes. Given the same symptoms, a general practitioner is cognisant that there could be a serious underlying problem but the probability is higher that it isn’t. As we were all taught in medical school, common things are common. It’s just that in this age of hyper-specialised, fragmented medicine, it takes a good GP to live by this adage.
We should be justly proud of Australia’s hospital system, that provides a standard of care envied by the rest of the world. When you have a leaking cerebral aneurysm or an evolving infarct there’s nowhere you’d rather be. If your appendix has burst or your acute illnesses have collided to make you gravely ill, you want to be looked after by the best possible team of specialists. But on countless other occasions, the timely intervention of a sensible GP is the only prescription needed to spare the angst, inconvenience and cost of hospitalisation.
The backbone of good medicine everywhere is robust primary care buttressed by high-quality specialist care. Done well, it has the potential to be comprehensive, satisfying and cost-effective. Yet, I can’t tell you the number of times that my hardworking colleagues are scorned for being “just” a GP. I used to dismiss it as a fringe view but I fear that this sentiment is implicit in the current political debate that has GPs firmly in its sight.
At a time when the world is waking up to the benefits of bolstering primary care let’s not be the country to insidiously erode it. By all means, Ley could pursue a “value signal” in healthcare – but not at the expense of general practice. The rising cost of healthcare is due to a domino effect and attempting to curtail it at the general practice end is unwise.
Inefficiencies in hospitals and the high cost of prescription drugs, each estimated by the Grattan Institute to waste a billion dollars annually, are arguably more important – as are the significant limitations in community resources. I have seen patients spend nearly a year in hospital waiting for the right kind of placement and others stuck because agencies like district nursing and palliative care are at capacity. Lets closely examine the disproportionate cost of futile care in the last months of life, estimated to be a quarter of healthcare spending.
Doctors are far more willing these days to ponder their role in making medicine sustainable – talk to them about the real-life dilemmas of balancing ethical, holistic care with an eye on the public purse. Combine that with insights from patients who don’t care who makes them feel better, as long as someone does.
Recently, when my mother felt unwell again, she sought out her own GP. I don’t think she has abandoned faith in her daughter but she has discovered the importance of having a trusted general practitioner. Now that’s what I would call a strong value signal.