Care for the Community
There is a lack of care of the community. Not only are warm friendly
and reassuring doctors more likely to contribute to their patients
cures than their more distant colleagues (Lancet 2001; 357;757-762),
but also one other study has shown that emergency department patients
appeared to attend less often when assigned compassionate rather
standard care. Due to the system our patients have very little
time to talk about their problems. There are huge waiting times
in casualties and when in hospital a patient is subject to dehumanised
medicine where they are treated with often technological efficiency
without any real humanity. There is very little feedback given
to GPs regarding patient care in hospital and this is particularly
applicable to private hospitals. Because of the nature of medical
training it is difficult for specialists to become involved with
the wider social implications of illness for an individual patient.
GPs - The Conductors of the Primary
GPs, in spite of their enormous role and influence in society,
are often alienated individuals who are very conscious of their
autonomy and individuality. They are often manipulated by the
large medical clinics that they work for. They expect to see seven
or more patients per hour with a minute payment for each consultation
which after tax is usually about $13 per patient. Often, because
they are bulk billed, patients take it as their right that they
should see a doctor for what they consider to be a free service
and often treat the doctor with disrespect. As consumers, they
complain loudly if they are kept waiting or if the GP does not
spend enough time with them.
The Failing Health System
Wide-spread dissatisfaction is currently being expressed by doctors
not only in Australia but also in the United Kingdom and Netherlands.
The British Medical Association recently balloted the UK's 36,000
GPs on proposals for a mass walkout from the NHS. There is a high
degree of morbidity within the medical profession through stress
and burnout. Associate Professor Peter Schattner has said that
the Doctors Mental Health Implementation Committee determined
from 1992 - 1997 that the suicide rate for NSW registered doctors
was 19.1 per 100,000 - 60% higher than the general population.
Within the context of general practice, there is no easy access
to community health services and other primary care services.
Doctors rarely get discharge summaries from hospitals. In cases
of psychiatric emergencies, and the treatment of drug addicts
it is rare that appropriate agencies can be accessed at the time
they are needed. There is usually no simplified database referral
procedure or even access for other health care agencies. Even
with a medical or psychiatric referral it is very difficult for
patients to be seen immediately, unless seen privately. GPs rarely
get early feedback about patient care from specialists, especially
Stresses that doctors, particularly GPs are under include
The Under-financing of General Practice
MBS item numbers are the rebates GPs get when they see patients.
The Australian Divisions of General Practice in the Consultation
Paper on GP financing states that "the problem with the
MBS item numbers is that within the context of Medicare these
item numbers do not reward quality of practice". This
means that the only way a GP can earn a reasonable income when
bulk billing is to see at least 6 - 8 patients an hour. The government
ensures that a minimum amount of money is spent through the MBS
item numbers, and does not reward the quality of care which comes
from longer consultations.
GPs - The Gatekeepers
In the health care system, the general practitioners are the
gatekeepers, in that they not only make money for themselves by
providing service, but also decide what drugs are given, what
kind of pathology and investigative procedures are prescribed
and to which specialists they refer their patients. The GPs control
the patients. The health funds control the money, and the hospitals
are the takers of both patients and money. General Practice has
become very hard work and the economic return has become much
less than it was around twenty five years ago.
Of all professionals in the Australian community, it must be
the medical practitioners in general practice who meet the widest
variety of people. People of all ages and socio-economic backgrounds
see doctors and share with them their personal and physical concerns.
It is these facts that make the responsibility of the general
practitioner pronounced. When a doctor meets a patient the doctor
can hasten or hamper individual and community development.
GPs have a tremendous and wide responsibility towards the healing
of the community. If they are to be effective as therapeutic agents
they also need to heal themselves so that they can heal others.
For many GPs, as well as nurses their status and value in society
is diminishing and it is of great importance that they have the
self respect and self empowerment to understand the great responsibility
they have towards healing in the wider sense. Healing encompasses
cultural change as well as change in attitudes. As the generalist
specialist the GP has a major role to play.
In some hospitals in New South Wales, there is so much specialization
there is no General Physician. GPs have to have a tremendous amount
of knowledge encompassing all aspects of medicine as well as very
significant and important communication skills.
GPs are in an unenviable situation. The amount of money they
are paid in no way compensates for the measure of responsibility
towards society. They are generalist specialists with an
enormous range of knowledge in all spheres of medicine and yet
are not recognized as such.
The System - Funding Drugs and
Technology - Not Health
However, people do not realise how distorted and perverted the
medical system is. Many patients, accept the status quo and do
not realise there is any other form of healing except taking tablets
and as long as they can have their cigarettes, drink their alcohol,
eat their McDonalds and drink their Coke they are quite happy
without realizing that they are programming themselves for progressive
degenerative and chronic disease in middle age and later life.
The patients have no conception of how to heal themselves. They
have no knowledge of good nutrition and supplementation. They
are absolutely in the hands of GPs and specialists who are themselves
the victims of a biomedical model that forces on them allopathic
treatments which over and over again can do them more harm than
good. The system does not treat human beings like human beings.
It treats them like cattle. The organisations and the bureaucrats
that support this system should be condemned for not seeing what
is going on and for what should be rightfully humane.
The Ivory Tower of the Specialist
The problem is confounded by the fact that many specialists do
not have any kind of joint consultation with GPs and do not give
them the credibility, which is due to them. Some live in their
ivory towers, overspecialized and over focused, and do not seem
to have an overall approach that GPs have. However, some of our
specialists are utterly brilliant and without their dedication
involving the art and science of medicine, thousands of patients
would be worse off, particularly within the acute sphere of medicine.
They are brilliant diagnosticians, scientists, and surgeons. The
problem is that these specialists are geared to treating disease
which is degenerative and which has already formed. Such diseases
as already mentioned are cardiovascular, cancer, arthritic, stroke,
diabetic, osteoporotic, and depressive illnesses. They are the
final common pathway of a process, which could have been prevented
by appropriate nurturing, lifestyle change and nutrition.
Patients are the unwitting pawns in this money game of the medical
system. Specialists are so specialized that they are often totally
ignorant of the total picture of the patient in terms of nutrition,
life situation, and overall morbidity. They rarely link up with
other specialists or health professionals to discuss the patient.
In terms of discharge from private hospitals, there is often little
follow up. In public hospitals, it is rare for GPs to get follow
up notes, and joint consultation with the specialist is virtually
unheard of. There are usually no specialists available in casualties
where only the junior doctors see the first admissions. Specialists
come into the picture much later. This is part of the tradition
of medicine in Western society.
The Money Game
It is obvious that the health system needs to be more publicly
accountable, and it is astounding that although the primary care
is the basic gateway for medicine, GPs are not able to have access
to proper resources for referral of patients or the ability to
plan overall care for their patients including particularly preventive
and nutritional care, because they are not reimbursed in this
way by the Medicare system.
It is now coming to a stage where corporatisation is dis-empowering
the GP and taking over the role as the arbiter of health to the
individual patient. The large corporate bodies know the power
of the GP and realise it can be accessed to bring in money through
the GPs connection with pathology and imaging facilities, and
specialists. The corporate bodies wish to take a controlling interest
of these facilities as well as of specialist practices. In this
process the GP loses power over the doctor-patient relationship,
and the commercial interests intrude between the provision of
care by the health professional and the patient.
The Commercial Pressures
The current pressures on the health system in Australia are fundamentally
commercial pressures, and the GPs are becoming employees of the
corporate bodies. The whole aim of these corporate bodies is to
keep costs down and to make profits for their shareholders and
themselves. Mayne is not only taking over general practices, but
also hospitals, pathology, radiology, pharmaceuticals, and aims
to take over health insurance companies. In so doing, they will
have enormous political leverage. This vertical integration gives
tremendous political power to these corporate bodies .
Profit Vs Healing
Because profit is the bottom line, patients are relegated to
being numbers in a share market and the faster and more efficiently
the patients are dealt with the happier the shareholders are.
In this process, we see the demise of the doctor-patient relationship
and the ethos of Hippocratic medicine. We see no understanding
of the nature of illness or disease, no understanding of the ability
of the patient to heal themselves through mind-body and nutritional
approaches, but an emphasis on competition and the survival of
The pharmaceutical companies serve to propagate this approach
and some of these companies have GDP's greater than countries
in the developing world.
The Pros and Cons of Evidence
As so-called evidence medicine continues to progress we continue
to see the failures of these trials. Only five percent of evidence
based research trials are adequate according to the editor of
the British Medical Journal. It is known throughout the world
that so called evidence based medicine with pharmaceutical companies
is biased and this is why fifty percent of pharmaceutical based
research is proven 'adequate'. This conspiracy is funded and enhanced
by the government and by the pharmaceutical industry. The International
Committee of Medical Journal Editors stated in their joint release
on September 13th 2001, that the use of clinical trials primarily
for marketing makes a mockery of clinical investigation and are
performed to facilitate regulatory approval of a device or drug
rather than test a specific novel hypotheses.
Prescription medicine sales have more than trebled in Australia
during the past ten years. The annual growth rate is around eight
percent and it is expected to average 8.1% over the next five
years. The Australian Pharmaceutical Industry turnover was AU$6.9billion
in 1999/2000 and prescription medicine sales only were AU$3.7billion
in June 2000. Globally the market is expected to expand and reach
US $one trillion by 2008
Adverse drug reactions in Australia account for 6 - 7 % of all
emergency hospital admissions and up to 22% of emergency admissions
of the elderly.
The estimated public hospital cost of drug related admissions
in Australia is $350million per year. It occurs in ten to twenty
percent of hospital in patients and causes mortality in 0.23%
In an article in the New England Journal of Medicine in 1998,
by three physicians, it stated that 51% of approved prescription
medicines have serious side effects not detected prior to approval.
Evidenced based medicine is the 'in term', but it does not appear
to living up to expectations, probably because it is too reductive
and deals with statistics and numbers of patients rather than
the whole picture or the whole person. We only have to look at
the statins and the way they diminish the efficacy of co-enzyme
Q10 and can make a patient more prone to cardiovascular disease.
The latest research into Cox 2 inhibitors indicates that they
may actually increase cardiovascular disease. The introduction
of the pill in the 1960's was followed by a large increase of
the incidence of breast cancer and still causes many side affects
including the suppression of the libido. It is still not known
how SSRI antidepressants work. The evidence for the carcinogenic
and teratogenic effects of chlorine in our drinking water is still
not acceptable by the authorities for obvious reasons. Evidence
based medicine is mainly reductive in its approach. It does not
see the whole picture. It does not understand that although an
allopathic treatment with one drug may work for an organ or a
system, it may not work for the whole person.
The Most Scrutinised Profession
in the World
In general practice in Australia , GPs are actually in fear of
using extended item numbers for longer consultations because they
fear being victimized by the Health Commission. If they see more
than a certain number of patients a day they will be put before
a review committee. This is all because doctors are not allowed
to achieve a middle way. and the system is compromised by corporatisation
and so-called financial considerations. It is also engineered
by the rapid technological and pharmaceutical advances in medicine
which have no scope for understanding the person, the psyche or
the whole body-mind which makes up a human being. In particular,
men do not want to talk about their illnesses. They just want
the quick fix. Mothers are so anxious about their babies that
they do not realise that it is good for their child to get a fever
because it boosts up their immune system so they can fight more
illnesses later on in life.
GPs - The Meat in the Sandwich
GPs are the meat in the sandwich. They feel compelled to provide
their patients with the drugs and antibiotics that the patients
call for and yet cannot give adequate care which requires a preventative,
nutritional and lifestyle approach as they are not paid to do
this. They thus have to produce band-aid approaches which serve
the financial needs of the pharmaceutical companies who wish to
promote their latest magic drug. Simultaneously as the most scrutinized
profession in the world, they are under the constant watching
eyes of the governmental Health Insurance Commission, and the
Medical Boards of the various states. Most GPs feel threatened
and often victimized by the medical boards which investigate them
upon virtually any complaint. In these situations, the GPs are
guilty until proved innocent. The principal of one general practice
has said that he feels restricted and rendered impotent by the
medical board in his state. He says that he has no control over
the system and is not adequately represented. He says he has to
be very careful how he handles patients to avoid a possible complaint
even if this may compromise proper treatment, for example, prescriptions
of antibiotics due to the insistence of the patient even though
they are not required for a viral infection.
The Health Insurance Commission is a public infrastructure that
maintains item and PBS numbers. The government is the prime mover
within the health system and leads its initiatives through different
agencies which express best practice guidelines for doctors. These
agencies comprise groups of specialized doctors.
The government has been planning for ten years to bring public
health planning into the field of primary care and are developing
incentive practice payments to create standardized protocols for
doctors within a wide variety of public health concerns, including
diabetes, cervical smears, immunization, asthma and mental health
etc. These bodies are also developing complete computerization
of the whole of primary medical care so that all patient data
and medical records are computerized and can be encrypted through
electronic key signatures for transfer to other medical sources.
The problem is these agencies do not express the views of the
majority of GPs. The protocols that they express have not been
discussed with the ordinary GP. They are also based on the biomedical
model, particularly biological considerations and do not deal
with the psychology of the individual to any great extent or the
latest advances in nutritional and mind-body medicine which could
save the government billions of dollars through preventative health.
Even though it does not appear this way, the GP is becoming a
technician of a supervisory board of specialists couched in the
terms of electronic media and accreditation procedures.
The Conspiracy against Healing and
There is an absolute lack of public education in medicine. There
is a lack of understanding of lifestyle. People no longer know
how to live. Making money seems to be taking precedence.
If we wish to create a healing culture, the three requirements
The support of the community is paramount if we wish to begin
to treat people in our society (most of whom end up sooner or
later as patients) as human beings. This process requires not
only the development of partnerships between the health providers
and the community and service coordination but also educating
the public in a general understanding of how to take responsibility
for their lives and the prevention of illness. We also need to
debate what quality of life is. In our society the new religion
is economic rationalism and we forget what it is to be a human
being. A major change of consciousness is required if we are to
survive with quality.
The answer does not lie in drugs alone. It lies in lifestyle,
prevention of illness, modification of diet, relaxation and exercise.
It also lies in creating a more surgent, caring and cooperative
integrating society which is less alienating and anomic.
ADDENDUM: Contributing Factors to the Demise of the Power
of the GP as Conductors of the Primary Care Orchestra