Deskilling – can we avoid it ?


My wife and I were trained in South Africa. Out of sheer necessity we were able to give anaesthetics, do Caeserian Sections and take out appendixes when we finished our Intern years. Over there there is no one else to do it in the hospital systems so you learn very early on to be a very procedurally orientated Doctor.

These skills were some of the biggest draw plasters for the people who recruited us as rural GP obstetricians to country South Australia in 2000. They wanted doctors who could deliver their babies, deal with the trauma and be generalists in every sense of the word. And we did exactly that.

People in the big smoke, the rule makers, however see General Practice as something different and over the years they have slowly but surely kept on deskilling us by changing the rules.

This was one of the reasons we left the rural community in 2003. The writing was on the wall and we could see that Country SA was not going to allow us to continue doing what we were doing. We moved to a larger town and sure enough, in 2016 that community no longer has any local obstetric services left.

Sadly the system did not stop there. There are numerous examples. GPs used to manage many joint related conditions by doing intra-articular aspirations and steroid injections. Once the skill has been mastered it was a straightforward process but it required time and costly consumables. Apparently not enough for Medicare to stop paying for it and consider it as part of a standard consultation. This resulted in many, perhaps most, GPs simply giving that skill away and a large cohort of GPs in training never learning it in the first place.

It did not stop there. In many large hospital’s medical students and trainees no longer get to see basic conditions such as ankle injuries. These patients are immediately handed over to a Physiotherapist and the medical team loses the training in assessing and managing of the vast majority of these presentations.

In a place like Canberra there are no longer any GP Obstetricians left and in fact no GP has any admission rights to any of the local hospitals for any condition.

That brings me to the reason for this post – my Clinic is one of the few remaining GP clinics in the ACT that still offer a casting service for fractures. It may not happen often, the fiberglass consumables are expensive, but we like to have the skills and ability to do this and teach our GP Registrars how to apply a proper cast. It would be a rare episode where we would charge a patient for this service but until April 2016 we had Medicare codes that we could use to offset these expenses – it turned out to be cost neutral but professionally satisfying work. It was also cheaper for the patient as the Physiotherapy department at our local Public Hospitals are charging them a hefty fee for all consumables used.

Apparently Medicare considers this a redundant service. In April 2016 they removed those item numbers and we now have to either charge the patient out of pocket for our consumables in addition to a normal consultation fee or turn them away.

This is yet another attack on our skills – to be added to the perceived inability of GPs to be able to educate diabetics, look after asthmatic or prescribe drugs properly to name but a few. We are increasingly being transformed from being multi skilled highly efficient generalists to pen pushers and referologists who sit behind our computers, rarely examine patients, order lots of tests and refer everything to some else who the bean counters have decided do things better than we do.

For old Dinosaurs like me this is a hard pill to swallow – for the next generation of GPs coming through the training process this is normality and they don’t even know what they are missing.

Twenty four years ago I obtained a Bachelors Degree in Medicine and Surgery. perhaps we should find a new name in 2016 for this qualification to describe a career increasingly comprising of data entry, referral letter writing, low level counseling and a tiny bit of Medicine.

Or we should find a way to fight the System and take our work back from all the Noctors and others who feel they can do it better than a GP. Sadly I don’t see that happening as only the old dinosaurs see this as a problem

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One Response to Deskilling – can we avoid it ?

  1. No words, just muted head-nodding agreement. The tragedy of course is that work is efficient (avoids costlier hospital costs), efficient and safe (provided appropriately trained)

    Patients having to attend hospital for conditions a competent rural doc can manage is crazy – increased costs to patient, travel, accom, time off work etc

    That said, closing down smaller units (espec rural hospitals) saves the Govt $$$$ and the consequences be damned.

    Sad.

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