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09 Oct 2018

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

It is time for doctors to become more determined in defending the critical importance of a medical-led model of care – even if does not directly benefit them to do so. Collaboration and ‘team-based’ care are words used when the role of the medical practitioner is to be diminished or their leadership subverted – usually without any reduction in their responsibility or liability.

Prescription by other groups or conduct of non-medical endoscopy are good examples of these ‘collaborative’ models of care. Often there must be medical ‘supervision’ i.e. the doctor bears responsibility but is moved further away from decision-making, the conduct of a procedure or direct patient care. Clearly, this is not in the patient’s best interest. Not surprisingly, there is often no evidence these models of care offer any advantage (in some cases, such as non-medical endoscopy, there is evidence to the contrary). Moreover, the diversion of more routine/simpler work deprives an increasing number of medical trainees of opportunity to gain basic skills and achieve appropriate training exposure.

The desire for pharmacists (and others) to push beyond trained scope of practice straying dangerously into medical territory is conceivably a strategy of self-defined job redefinition in order to improve market share and profit, given how aggressive the pharmacy retail market has become. The conflict that all pharmacists face when offering ‘medical advice’ to patients needs highlighting. When a doctor writes a script (or not) there is no change in the consultation fee. By contrast, whenever a pharmacist/retailer persuades a shopper to buy something as a result of their advice, they make more money.

The Victorian Government funding of pharmacies to provide the MMR vaccine and the truly perplexing $100 pain consultations are policies that push the patient out of GP-centred care i.e. away from the trained and experienced professional able to genuinely help. At $100 a pop for potentially ill-advised direction from a pharmacist who lacks detailed anatomy or pathology knowledge or any greater sense of medicine or what else might be wrong with a patient seems awfully expensive compared to the cost of any engaged, family GP who costs less and is able to achieve a better, holistic outcome. Contrary to what some believe, there is also absolutely no difficulty in getting access to a GP at any time. Governments who allow marginalisation of doctors/GPs to occur are therefore knowingly compromising patient care.

If doctors dispensed medications while only covering the cost of the dispensing, there would be less cost to the patient and system, and no perverse profit incentive as exists for the pharmacist. This represents the ultimate in efficiency and convenience for our patients and the healthcare system.

I can hear the usurpers citing benefits from drug companies to doctors as a prescribing incentive. This is nonsense, but let’s examine it nonetheless. Non-educational benefits from industry to doctors is non-existent. My plumber can give me notepaper and a pen with company details, but a drug company cannot. It is acknowledged that all professionals are required to attend conferences that are supported by industry, there is however no evidence that this support of educational activities changes prescribing activity or causes any harm to patients. Pharmacists and nurses also attend the same conferences. Conferences in all industries (medical and non-medical) work similarly and there is no endemic problem with professionals the world over managing their decision-making adequately.

In addition, however, pharmacies receive representation and benefits from drug companies to stock certain items in their stores and promote certain products. Any retail shop owner obviously makes more money if they can persuade shoppers to purchase, for a pharmacy this might occur as a result of providing ‘medical advice’. Sometimes pharmacy staff are ‘tested’ by mystery industry shoppers coming in with a certain problem and asking for advice. If the pharmacy staffer promotes certain products (regardless of the evidence base or lack thereof) to the customer, there can be rewards. I would imagine the pharmacist therefore to have more difficulty managing their conflicts than any doctor.

Doctor errors are given wide public coverage and Government seems bent on maintaining a very strong regulatory presence. Equally then, the pharmacists and all those who want extra responsibility, if they get it, are to be bound by the same regulatory and training standards. Let them be similarly accountable when they make a mistake. Indemnity insurance costs must go up to cover the increased risk and they will need robust continuing profession development approved by the appropriate regulatory body and so on. No short-cuts!

Collaboration is a euphemism for role substitution and we (Government included) need to stop allowing it under any guise, no matter how seductive the model looks on the surface. What usurper groups manage to gain, they should be solely and proportionately responsible for – they cannot take the cream but leave the real work and responsibility to doctors given the training and experiential requirements of future generations of doctors. There is to be no more medical ‘supervision’ of other groups doing a doctor’s job. We have a record number of doctors able to competently do medical work – there is simply no need for the type of role substitution models being peddled by usurper groups at present. 

If the Guild wants to be truly collaborative, put profits aside and help embed pharmacists in general practices to perform medication reviews and support a true multi-disciplinary, doctor-led team.

 


Published: 09 Oct 2018