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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

Pro Sano Medical Scheme has noted a significant increase in serious ailments requiring hospitalisation, such as cardiovascular illness, hypertension, strokes and heart attacks, as well as psychiatric conditions such as depression. Many of these conditions are stress-related and are being seen across the board, in people of all ages and income levels.1

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.2

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.3

Secondary care, too, has been affected, as many patients go directly to a specialist to reduce the costs of additional primary care. Hospitals are run as businesses, as are some medical aids, where they are mutuals and are accountable to their members. As these businesses become increasingly overstretched, tensions can begin to arise between treating escalating patient numbers, reducing costs, and maintaining patient safety.

Dr Graham Howarth, Head of Medical Services (Africa) explains: “We have heard that some private hospital groups, in an attempt to save money, employ nurses rather than midwives on their labour wards, but we cannot comment on the truthfulness of these claims. A lack of specialisation can lead to increased intrapartum problems and the potential for increased complaints or claims.”

A lack of specialisation can lead to increased intrapartum problems and the potential for increased complaints or claims

Acting within your competence is important. 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 because of staff shortages.

Dr Ming-Keng Teoh, MPS Head of Medical Services (Asia), explains that some medical private practitioners choose to maintain their income (as patients turn to the public sector) by taking on a wider range of treatments (eg, GPs undertaking cosmetic procedures), as well as patients (paediatricians seeing adult patients, obs and gynae 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. 

Maintaining standards

In South Africa, there has been speculation that the recession has led to an increase in fraudulent claims. These could be patient or doctor-related. Dr James Arens, Clinical Operations Executive of Pro Sano, says: “A practitioner might load their bill, so that a legitimate procedure is padded with all sorts of additional codes, which patients often do not understand or think to question.”

Remember your professional obligations to be open and honest at all times. Despite an increase in patient numbers, you should always take a thorough medical history and an examination if necessary – and document both. Record-keeping standards can easily slip if a consultation overruns, 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 rebook.

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. 

You have a professional obligation to work within your competence

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.”

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 longterm 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. 

The worst of times

Delaying a visit to the doctor

In South Africa, the loss of medical aid usually follows job losses, and so unemployed patients defer healthcare treatment and only seek help when acutely ill.4 This has resulted in patients presenting to primary care physicians later in the course of their illness, with more complications. Sometimes, patients go to see their GP with a medical aid card that they have borrowed from a friend or family member.

GPs need to be vigilant and check that the card belongs to the patient in front of them. 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 can lead to a complaint or a claim, so it is important to have a low threshold for inviting 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 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.

Private practitioners are frequently faced with the ill patient who cannot pay and they too must be compassionate and not put that patient at harm by denying appropriate care

Dr Brian Charles, Emergency Physician and MPS Consultant, based in Barbados, 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.”

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”.5 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.6 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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