Optimal patient care
[ UniNews Vol. 15, No. 5
3 - 17 April 2006 ] By Paul Monagle
Are we asking the wrong questions about medical servicing?
A recent editorial in The Age (6 March) raised the issue of medical overservicing via pathology testing and asked how we limit the number of unnecessary medical tests
This, unfortunately, asks the wrong question.
The right question is: “How do we ensure that the right pathology tests get performed on the right patients at the right time?” Our driving force must remain the optimisation of patient care, within the confines of the resources available.
In discussion on the issue earlier this month, much was made of the question of doctors being driven by financial incentives from pathology laboratories, which is patently illegal. However, even in our public hospital system, where there is no possibility for such incentives, the volume and costs of pathology testing are steadily increasing.
This would suggest that there are alternative key drivers – for instance, fear of litigation is an often-cited cause. The likelihood of this truly driving the bulk of medical practice in Australia is low.
However fear of being wrong (failure), fear of being chastised by senior colleagues, and fears for patient well-being are often the real fears, just less well verbalised. Doctors have insurance to cater for legal action. Feeling that you contributed to the poor outcome of a patient because you missed something is a lot harder to manage.
The challenge is to maintain perspective on an appropriate level of investigation given the history and examination findings of each patient. Perhaps more importantly, although less often described, as a driver of medical practice, public expectations cannot be underestimated.
Just as patients exert considerable pressure on prescribing practices, so does the public perception that a ‘good doctor’ orders lots of tests, exert pressure. Tests and medications validate the visit to the doctor for many patients.
As a separate issue, our population is aging, and the introduction of a number of preventative programs increases, not decreases, pathology testing. The aim of preventative programs is to reduce the treatment burden by preventing disease, not necessarily to reduce the diagnostic burden required to diagnose disease early, and monitor progress. Thus reviewing the pathology budget without assessing the impact on the therapy budget is misleading.
So how should we deal with inappropriate pathology testing? Improved medical education is the answer in most cases. This is the only sustainable way to improve clinical practice. Practical use of pathology testing needs a greater emphasis in undergraduate teaching programs.
Paramount is the appropriate development of academic pathologists, whose focus is on teaching and community knowledge transfer. To date no attempt has been made to influence community expectations, yet such a strategy is vital.
The Royal College of Pathologists of Australasia spends the majority of its resources on the important work of training pathologists. However, there is a real need for pathologists to get involved in the postgraduate teaching of all medical and surgical subspecialties, including general practitioners.
At the coalface, it is clinicians who order the tests, not the pathologists. A successful method to improve the way doctors use pathology services is to rotate the training of doctors through pathology laboratories as part of their core training, to teach them the fundamental utility of the tests that they order.
The most important barrier to achieving such a goal is the lack of funding for training positions by state and federal governments. Despite these needs having been recognised in the report for the Federal Department of Health and Ageing titled Analysis of current laboratory Medicine (Pathology) teaching practice in prevocational and general Practitioner vocational training, no substantive action has been taken.
The increased number of medical student places that have recently been funded means there will be a large number of new medical graduates requiring intern placement in hospitals. We must take the opportunity to allocate sufficient funding for training these new doctors in the appropriate use and requesting of pathology tests.
A proactive co-ordinated approach to increase pathology teaching through all medical and surgical postgraduate training would serve the Royal College of Pathologists of Australasia, our governments, and the people of Australia, well.
Professor Paul Monagle (right) is Head of the Department of Pathology at the University of Melbourne.
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