newsGP - Who are the pathology nudge letters really targeting? - RACGP
Rather than rogue doctors, these letters seem to have been sent largely to GPs who treat our most vulnerable patients, writes Deborah Carrington.
Last week, the Department of Health sent out a new wave of 'nudge' letters.
We have been through this before. The announcement was met with a mixture of fear, anger and then – confusion. This time the letters were targeting, of all things, pathology requests.
Vitamin D, Iron studies, Thyroid function tests, Vitamin B12.
I have not received a letter personally, but this may only be due to being on maternity leave for some of the targeted period.
I do know that all GP registrars are taught early in their training about rational ordering of investigations. As a medical educator, this is one of the first lectures I deliver to our first term GP registrars.
We teach them about the need to reduce wasteful Medicare spending, the risk of increasing patient anxiety and the problem of finding incidentalomas. We teach them not to take a 'scattergun' approach to ordering tests.
In contrast, I would argue that these nudge letters are adopting a 'scattergun' approach to catching out GPs.
Though is it possible that a small number of practitioners out there are ordering large panels of tests without a clear clinical indication, I don't think these recent nudge letters are targeting those GPs.
Judging from the response on social media, these letters seem to have been received largely by GPs who treat our most vulnerable and marginalised patients.
They have also been received predominantly by female doctors, which is maddening given that the tests being 'nudged' are legitimately required for so many women's health consultations.
So, who are these wayward doctors who have received a warning this week about their clinical practice?
They are the GP who has weekly bulk-billed appointments for the teenage girl with an eating disorder. Each week they do their best to keep them out of hospital, spending hours calling multiple services and begging for someone – anyone – to help them.
They are the GP who sees multiple presentations a week of female patients with fatigue, low mood, menstrual irregularities and menopausal symptoms. Long, complex histories and patients with multiple layers of carer stress, COVID fatigue and no time for self-care.
They are the GP who cares for refugee patients, patiently taking broken histories with interpreters. They must screen for nutritional deficiencies whilst holding space for horrific stories of abuse and trauma.
They are the GP in an Aboriginal Health Service, doing their best to provide holistic and culturally safe care. It is hard to ask a patient to return for another blood test when they must travel long distances and overcome immense anxiety to attend appointments.
They are the GP in a rural town like mine, where birthing services have been suspended.
With the nearest maternity hospital 100 km away and most appointments via telehealth, GPs are often the only way these women have a regular physical examination. These vulnerable mothers need long antenatal appointments. In addition to low iron and Vitamin D, they carry realistic fears of hitting a kangaroo or giving birth on the side of the poorly maintained highway.
They are the GP carrying large numbers of mental health patients who have slipped through the cracks of every other service.
Having long ago given up on finding a local psychiatrist with open books, the GP is doing their best with remote telehealth. They sigh as the psychiatrist's letter requests another long panel of blood tests and regular ECGs.
They are the GP who selflessly continues to care for their patients in nursing homes, in spite of poor remuneration and the stress of multiple phone calls out of hours. They are doing their best to manage confusion, falls and weight loss in a system with no support and no time.
They are the GP who has been trying for weeks to get their patient accepted by the public hospital outpatient clinic. After three rejected referrals, they are told that, in spite of their patient's PR bleeding and concerning change of bowel habit, they will not be seen until the GP adds iron studies to the hospital referral form.
Nudge letters are not harmless.
They inflict enormous anxiety and dread amongst GPs and inject a real sense of fear into clinical decision making. Many GPs are already feeling burnt out and are contemplating how to transition out of the profession.
Trainee numbers are at a frighteningly low rate.
Targeting GPs in this way is inappropriate and discriminatory against those who practice high rates of women's health, mental health and aged care.
How much taxpayer money goes into the distribution of these letters?
It seems contradictory to be telling GPs to stop spending money ordering blood tests whilst funding is being used in this way.
If the desire is to cut back on unnecessary tests, why not simply fund some education for GPs through gplearning or NPS modules? Why not ensure that Health Pathways are updated to include this recommendation?
This would have been a respectful and safe way to communicate with us, that would not have caused the distress and outrage currently burning through the profession.
We know there is wastage in the healthcare system. We know that good stewardship of Medicare is a part of our professional responsibility. However, given that general practice receives such a small share of healthcare spending, this cannot be the most effective means to target spending.
Many GPs who have been sent letters this week are working in rural and low-income areas. They are holding together the aged care system with their bare hands whilst resources and funding disappear.
They are doing the heavy lifting in a broken mental health system.
They are doing hard medicine with challenging patients. They are filling gaps, picking up pieces and taking on jobs nobody else wants to do.
These GPs don't deserve threatening letters. They deserve a standing ovation and a significant pay rise.
These doctors are not the enemy of the healthcare system – they are keeping it together.
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