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The worst of times

Unemployment reduces wellbeing. Recession raises the demands on healthcare systems and makes it harder to pay for them. Doctors worldwide are having to adapt and change to cope with these additional pressures, says Sarah Whitehouse

The impact of the recession on healthcare reads like a gloomy checklist of the multi-symptom patient: increased stress, depression and anxiety; an increase in alcohol consumption; an increase in stomach and digestive problems; and an increase in obesity.

A study by the Insight Research Group of 300 UK GPs reported that 17% noted an increase in requests for terminations of pregnancy specifically because of financial concerns.1

Skin complaints are even on the rise. Research by the British Skin Foundation suggests that nine out of ten dermatologists have noticed a marked rise in eczema, psoriasis and other skin conditions triggered by stress.2 Most dispiritingly, international research suggests that for every 1% increase in the unemployment rate, there is a 0.78% increase in the rate of suicide.3

The impact on doctors

But what does all this mean for doctors? Primary healthcare, often the first point of contact, has been hard hit. The Insight Research Group also reported that 77% of UK GPs feel there has been an increase in new cases of mental health conditions in the last four years directly linked to the economic climate.4

Remember your professional obligation to take a thorough medical history and an examination if necessary – and document both

Secondary care, too, has been affected. In the UK, almost 6,400 people were admitted to hospital with stress between the period January – May 2012, 47% up on 2007-8, when the economic crisis hit.5 In the Caribbean, public healthcare systems are being stretched as the recession forces more patients to move away from private care. Dr Nancy Boodhoo, MPS Head of Operations, Caribbean and Bermuda, says that this is a particular issue for obstetric care because of spiralling costs.

Maintaining standards

One of the biggest challenges facing doctors is balancing an increase in patients’ needs with maintaining high standards of care. Remember your professional obligation to take a thorough medical history and an examination if necessary – and document both. Record keeping standards can easily slip if a consultation over-runs, but it is important to stop and make notes before rushing to see the next patient.

Be aware too of “by the way” comments, where symptoms might be mentioned in passing as the patient is on their way out of the door. These symptoms can often be the real reason behind an appointment, so make sure you record them. If it is not urgent, or you do not have sufficient time to give the patient your full attention, you should ask them to come back.

If you find that you are so overstretched that the situation is in danger of putting patient safety at risk, or your health begins to suffer, you should raise your concerns within the appropriate channels, for example a senior colleague or your employer.

The worst of times

Act within your competence

MPS has received a number of calls from hospital doctors who feel uncomfortable at being asked to provide cover for an area they do not normally specialise in due to staff shortages. For example in psychiatry, adult psychiatrists are often asked to step in and cover children and adolescent psychiatric care.

Dr Ming-Keng Teoh, MPS Head of Medical Services (Asia) explains that some medical private practitioners seek to maintain their income (as patients turn to the public sector) by choosing to take on a wider range of treatments (eg, GPs undertaking cosmetic procedures), as well as patients (paediatricians seeing adult patients, obstetrics and gynaecology consultants examining patients with breast lumps).

Doctors who choose to do this are practising in areas beyond their expertise and may fail to refer appropriately. You have a professional obligation to work within your competence – and should raise your concerns with a senior colleague or employer if you are asked to perform a procedure that you are unsure of.

Managing expectations

Speaking this year at an MPS conference for newly-qualified consultants, MPS Head of Medical Services Dr Nick Clements said: “There has to be a balance between the patient’s interests, the need to control budgets and where the doctor’s duty lies in these difficult circumstances. Often, the buck seems to stop with you, the doctor. If a patient cannot get the treatment they want, or the drugs they want, they will blame the doctor who is saying no. Doctors need to have the right communication skills to handle these situations carefully and manage patient expectations.”

There has to be a balance between the patient’s interests, the need to control budgets and where the doctor’s duty lies in these difficult circumstances. Often, the buck seems to stop with you, the doctor

Some patients see making a claim as a financial opportunity in these tough times. In Ireland, the average size of claims against doctors has increased by 37% between 2007 and 2011. Dr George Fernie, MPS Senior Medicolegal Adviser, says: “There has always been tension in Ireland with the public and private mix, but it’s been magnified with the recession. We have seen a case where a doctor reasonably asked a patient on long-term prescription to come in for a review, but the patient felt that this was financially motivated and lodged a complaint.” You should always explain your reasons for calling a patient in for a review, clearly explaining the health benefits and the need for follow-up.

Delaying a visit to the doctor

In some countries, the economic downturn means that patients are accessing healthcare less frequently. In Ireland, those without Medical Cards are increasingly putting off making an appointment, which can have an impact on early diagnosis and the treatment of long-term conditions. Requests for telephone consultations are on the rise, and with them the risks of potential missed diagnosis.

Failure to diagnose is a common cause of a complaint or a claim, so it is important to have a low threshold to invite the patient in for a review. Dr Brian Charles, Emergency Physician and MPS Consultant, based in Barbados, says: “A particularly worrying trend has been patients ‘waiting to get better’ before seeking medical care, particularly those with medical insurance who have to pay upfront and wait for reimbursement later. This has resulted in patients presenting to primary care physicians later in the course of their illness, with more complications.”

It is important to have a low threshold to invite the patient in for a review

Despite the impact of the recession being less marked in Hong Kong, Malaysia and Singapore, which generally have more private practices and less welfare spending, Dr Teoh says: “Recession has had an impact in the public sector, reducing the number of consultations, as patients are less likely to take time off work to seek healthcare. They cannot afford the time, rather than they cannot afford the cost of healthcare itself.”

A reduction in patient numbers has also led to many doctors in private practice resorting to longer opening hours, more practice promotion activities and more turf battles between doctors. The respective Medical Councils do not permit doctors to promote their practice or advertise or canvass for patients, and so doctors may find themselves in murky medicolegal waters if they do try to seek new patients in this way. They are advised to consult and seek legal advice if unsure.

Where does a doctor’s duty lie?

The conflict between a doctor’s duty to their patient, and the patient’s ability to pay, can be all too real. An MPS GP, based in Ireland, describes a case where a patient with depression wanted to wait to pick up his anti-depressant prescription until he was paid. The GP was concerned – the patient had severe depression and was at risk if he did not take his medication. The GP spoke to the pharmacist and agreed to postpone the fees for a few days until the patient was able to pay.

Dr Charles says that in the Caribbean: “Private practitioners are frequently faced with the ill patient who cannot pay (or at least, cannot pay at the time of the encounter), and they too must be compassionate and not put that patient at harm by denying appropriate care. All must be done to ensure that these patients are stabilised and properly referred onwards for the complete care they need.”

A patient with depression wanted to wait to pick up his anti-depressant prescription until he was paid. The GP was concerned – the patient had severe depression and was at risk

Yet doctors must retain a degree of realism. They cannot be responsible for putting right the social and financial woes of all their patients, as well as their ill health. To do otherwise may well result in burnout for the already overstretched doctor. In the UK, the GMC, in Good Medical Practice, states that good doctors “make the care of their patients their first concern”, but “must make good use of the resources available”.6 Unfortunately, these are not finite.

Conclusion

One small positive can be gleaned from the UK GP research into the effects of the recession on healthcare: 38% of GPs believe that patients who smoke are giving up or cutting down to save money.7 However, the pressure cooker of reduced health and increased demand for healthcare continues to affect most doctors.

Dr Clements sums up: “Do the best you can with the resources available. Make sure that any resource-related decisions are fair and based on clinical need and remember to be open and honest with patients about the constraints.”

References
  1. Insight Research Group, The Austerity Britain Report: The Impact of the Recession on the UK’s Health, According to GPs (2012) [A survey of 300 UK GPs]
  2. Macrae F, Recession is bad for the skin as stress triggers rise in itchy conditions, Daily Mail (31.7.12) [Survey by the British Skin Foundation conducted at the British Association of Dermatologists’ Annual Conference July 2012, 105 doctors and nurses surveyed.]
  3. Mulholland P, The great depression? Irish Medical News (27.8.12)
  4. Insight Research Group, The Austerity Britain Report: The Impact of the Recession on the UK’s Health, According to GPs
  5. Laurance J, Rise in hospital admissions for stress is blamed on the recession, The Independent (12.09.12)
  6. General Medical Council, Good Medical Practice p6-8 (2006)
  7. Insight Research Group, The Austerity Britain Report: The Impact of the Recession on the UK’s Health, According to GPs
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