Care is not delivered in a vacuum

3798267293_030d8688bd_zGeneral practitioners (GPs) are the most used health service providers in Australia. In 2010–11, an estimated 14.5 million people aged 15 years and over (82%) had seen a GP at least once in the previous year, with 11.8 million seeing a GP more than once.  At that time in 2011 that there were 43,400 general practitioners in Australia, 43% were women and they worked an average of 42 hours. An earlier census reported that the average age of a GP was 49.3 years with almost one in three older than 55 years. Yet studies seldom report the impact of this demography on the professional advice offered in practice. If it is relevant to tailor health care advice to the ideas and expectation of the patient or client than by corollary it is relevant to consider the personal experiences of the healthcare professional who offers a service. We know for example that lectures, guidelines and protocols aimed at doctors may have less influence on whether a patient receives evidence based care than staff room conversations, peer pressure, the views of opinion leaders or the impact of personal experience within an individuals circle of influence. In research on innovations delivered in the consultation, the clinician is a significant confounding variable. A fact that is rarely mentioned in the limitations of the study.

Primary care clinicians work in “communities of practice,” combining information from a wide range of sources into “mindlines” (internalised, collectively reinforced tacit guidelines), which they use to inform their practice. Gabbay and le May.

Consider for example a recent report that the diagnosis and treatment of malaria by doctors was derailed by the influences described above. What is also recognised is that when doctors become sick or treat their own families they don’t necessarily follow clinical guidelines. What then might make it more likely that doctors provide evidence based care for chronic and complex conditions? With one in three doctors over the age of 55 it is likely that many general practitioners, their partners, families and friends will experience the onset of chronic illness- diabetes, low back pain, depression, cancer etc. They are also going to be invited for screening- colorectal and breast cancer. Their attitudes and experiences may well predict how their patients will be treated. For example in a study in which doctors were asked their views on screening their patients for alcohol abuse, the authors, Anders Beich and colleagues did not report on the alcohol consumption of the participating doctors or their experience of alcoholism in their close family or friends. One participating practitioner was quoted as having said:

To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me.

Therefore the doctor is a key stakeholder in the process of health care not just by virtue of a professional role but also with respect to his or her personal history and prejudices. This has implications for diagnosis but also for treatment. Patients need to be seen and heard. When the doctors senses are impaired by personal history it is possible that their assessment of needs,  symptom severity or risk may be limited.  What may help innovators is empirical evidence that addressing this question in a defined setting may help deliver better outcomes for patients.

Picture by ReSurge International

2 thoughts on “Care is not delivered in a vacuum”

  1. Solo for the last 22 of 49 years, with limited interaction with other GPs, my practice is possibly informed to a greater degree than average, by learning from my patients. They are virtually all repeat customers as well, so mistakes have mostly come back to be discovered. In my paper records, there are two small tick columns, for +/- used and +/- effectual for Rx advised. These help me to remember to check. Software could be set to automatically first bring up the last visit notes with these as tick boxes.
    The gut feelings of conscientious, caring GPs are probably “not inferior” to guideline based medicine a lot of the time.

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