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Dr Dave Nixon. Photo/Supplied

A fatigued doctor on why general practice needs to change

Dr Dave Nixon says that the GP shortage means we can't practise like we did in the past, but GP-style consultation is still the best medicine.

When Taupō GP Dave Nixon retired in 2017, he was burnt out with fatigue and burning up with frustration at the bureaucracy in which he was forced to practise. “If I’d stayed, I would have died,” he says. “It was miserable because of the load, and knowing there was no light at the end of the tunnel. You always felt you were going backwards.”

A large part of the problem was bureaucratic patient-compliance targets, for such things as vaccinations, cardiovascular risk assessments and mammograms. “It’s time-consuming, and although there’s a financial reward for meeting targets, it barely pays for the labour to do it. It sounds good and well motivated. The trouble is, the ones who are going to gain the most are those who don’t come in for a free check, so you get the ‘worried well white’ turning up all the time and the high-risk people aren’t getting assessed. We all know people in low-decile societies have the poorest compliance rates, so someone in Epsom will be able to get their targets much easier than someone in Tūrangi.”

When the targets are met, they just get harder, he says. “The more a system is regulated, the more you are doing tasks that you don’t see value in, the less pleasure you get from a job and the less reward you get from the job, so the less you want to stay in a job. If people then don’t go into general practice, you have higher patient-doctor ratios and the whole thing is on a spiral, and that is what is happening now. It’s an endemic issue with society, not just general practice.”

Nixon says he started seeing patients at 8.30am every day, never had lunch and got home at 7pm every night. The doctor who replaced him lasted 18 months before leaving. “It was too much.” The practice was in the top 10% of earners because it received extra funding for its low-decile population, but saw “huge numbers” of patients.

Because people were waiting longer to see a doctor, they’d often turn up with a shopping list of multiple issues. That led some GPs to restrict patients to one problem per consultation or charging more for an extended appointment. “That’s the worst decision you could make. I hate that world, because we are disincentivising people to raise things and eroding holistic care. You start to partialise patients, and that’s what we criticise specialists for.” And in an ageing population, the needs were more, not less, complex.

The practice shifted to a Health Care Home model about five years ago, but Nixon doesn’t believe it helped, saying predictions of 20-30% of patients who could be diverted to other services or have their appointments delayed by phone triaging weren’t realised. And, he says, the model has risks, particularly if the triaging is being done by a doctor who doesn’t know the patient well.

“If you’ve got a patient who is eloquent, educated and able to represent their history really well, you’ll get a more accurate assessment of what is going on. If you have someone who is not as well educated or articulate, then you might not get the full story. The burden is on the doctor to make sure they are not missing something. There is definitely risk, because the doctor is saying, ‘I don’t need to see you’, but you are the last cab on the rank, so you take the responsibility.”

After a year away, part of which he spent developing palliative care in Bhutan, he’s now working part-time in Tūrangi.

So, are we all just pining in vain for a return of the long-gone Dr Finlay’s Casebook days, when the GP arrived at our bedside with his Gladstone bag and stethoscope to soothe our fevered brow while he drank a freshly brewed cuppa?

Nixon says not. “We can’t practise like we did in the past and we do have to make changes. But the GP-style consultation is the most efficient use of health resources. We are trained to be the gatekeeper and filter. The best way of channelling those resources is through a funnel that is wide at the top, through a very narrow tube at the bottom, so we filter out as many things as possible. That’s the most efficient and best for patients to keep them out of secondary and tertiary care. And that requires GP-level skill.”

This article was first published in the August 10, 2019 issue of the New Zealand Listener.