“Defining the individual and collective responsibilities

of the future Family Doctor”

 

 

PhD Les Toop

 

                                                      

Biography:

Médico de Família em Phillipstown, South East Christchurch, na Nova Zelândia, desde 1986. Realizou a sua formação pré e pós-graduada em Bristol, Inglaterra, e Edinburgo, Escócia, e chegou à Nova Zelândia em 1978.

É também Professor de Medicina Geral e Familiar e Director do Departamento de Saúde Pública e Medicina Geral e Familiar na Faculdade de Medicina da Universidade de Otago, Christchurch, Nova Zelândia. Está activamente envolvido na formação pré e pós graduada, com ênfase particular na promoção da prática clínica apoiada na evidência  e na investigação clínica comunitária.

É Director da Pegasus Health e é membro do Council of the Royal New Zealand College of General Practitioners. Tem sido um grande defensor do trabalho em equipa colaborativo em Medicina Geral e Familiar e da importância da formação profissional interdisciplinar. Ele continua a lutar pela  disseminação de mais informação independente sobre saúde para o consumidor.

 

Comentários / Comments

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 TIAGO VILLANUEVA | LUÍS FILIPE CAVADAS | BRUNO HELENO | GUILHERME MENDES | JUAN GÉRVAS | GEMA PONCE | LILIANA LARANJO | ANA LUÍSA NEVES

QUESTIONS FROM TIAGO VILLANUEVA

Dear Les, 

Firstly.  I’d like to give you a very warm welcome to this Virtual Conference.  It’s quite an honour to have you with us over the next few days. I am going to kick-off this conference with a few questions.

 – General Practice in New Zealand is not very well known in Portugal, which in partly has to do with the geographical distance.  However, I guess there is an empirical perception that General Practice in New Zealand is very advanced, and on par with state of the art practices around the world, namely Europe, North America and Australia. How do you gauge the perception in New Zealand, of General Practice in European countries (with the exception, perhaps, of the UK, which is probably well known)?

– Could you briefly explain to us how GP training  is organized in New Zealand? In your opinion, what are the most important and cutting-edge training methodologies to train good future GP’s?

– You did you medical and GP training in the UK, and then moved to New Zealand. What made you establish your career on the other side of the world?

– In your bio, you mention you are a strong advocate of interdisciplinary professional education. This reminds me of some medicine graduate programs, like the one at St George’s University in London, where medical students get to learn and train together alongside nursing and physiotherapy students, just to mention a few examples. In your opinion, should GP trainees train alongside other healthcare professionals during their vocational training? If so, why?

– You also mention in the bio that you continue “to campaign for greater provision of independent consumer health information”. Are you also engaged in campaigning for independent drug information for health care professionals? Do you feel it is also an important issue?

– Lastly, why did you choose this title for the conference?  

Many thanks, and looking forward to your reply.

Best wishes, Tiago

Dear Tiago and colleagues

It is a pleasure and an honour to have the opportunity to have an extended conversation with a group of clearly highly motivated and intelligent your doctors.  I congratulate you on your initiative.  I will answer your questions in 2 or three bites as in the next 24 hours I have a number of engagements that I will try and fit my writing around

New Zealand has a system which from a Dr Patient perspective still resembles a form of the UK system.  Appointments are 15 minutes mostly and patients copy anything from 0 to 50% of the fee.  In cross country Studies NZ GP rates very highly for patient satisfaction and is probably as evidence informed as anywhere.  Computerisation is close to 100% although GPs use them variably. It is a mature workforce with the average age of GPs in the early 50s.  Recruitment was a big issue for a decade and a half, seems to be improving now, so there are major workforce issues ahead.  Close to 50% of GPs trained elsewhere and many NZ graduates work overseas in English speaking countries.

Being so far away from Europe most NZ’ers have little first hand knowledge of countries beyond as you say the UK where many have visited and many GPs have worked in their post grad years. My own experience of Gen practice in Non UK European countries is limited to those docs I have met and spoken to at European Wonca conferences over 20 years and having visited some practices on sabbatical (notably in Germany and Belgium).  I have to admit having grown up in the UK I never made it on my travels to Portugal, who knows one day perhaps!

GP training is in transition with a more structured approach likely. Currently having done a period (2-5 years) in hospital jobs, aspiring GPS join a training scheme which starts with an intensive year in a training practice with day release course work followed by a written and clinical exam. They then enter a period of advanced vocational training, details of which can be found on the Royal New Zealand College of GP website http://www.rnzcgp.org.nz/pathway-to-fellowship/

I believe the recipe hasn’t really changed.  In my opinion. GP training has to combine an apprenticeship, working with a wise and capable mentor as role model and teacher, combined with a skills and attitudes curriculum which encourages reflective practice, demonstrates the particular aspects of community based generalist medical care and, finally most importantly, encourages the development of a healthy degree of critical and sceptical thought for those entering an environment which is both complex and full of competing external influences / vested interests of one sort or another.

Fate mostly, I came to New Zealand as a medical student to do a final year elective in 1978, I was immediately used as a locum junior doctor and I fell in love with the country, the people and the work seemed much more relaxed than the UK of the time (late 1970s). After qualification (in Bristol UK) I went back to NZ for two years and then back again to the UK to finish vocational training and ended up doing academic general  practice with my mentor Prof John Howie in Edinburgh. When an academic position came up in the mid 80s in New Zealand I tossed a coin, came, found a practice – and here I remain 24 years later!

Yes, I believe GPs and other professional groups (e.g. nurses and pharmacists) should wherever possible learn and work together in training, understanding each others roles is a pre requisite for true collaboration.  Further, I believe there are possibilities for these groups to engage in shared continuing education. We have been trying to work on this model for 15 years at Pegasus; I may explain more of this later.

Independent information for health professionals?  Yes I believe it is crucially important for patient safety, and yes I have spent 25 years promoting rational prescribing and use of laboratory tests both locally and nationally ( I helped set up and chaired for a number of years PreMeC the national preferred medicines centre (now replaced by BPAC NZ) .

The educational team I am part of produces a number of key resources and 90 % of local GPs. practice nurses and (more recently) pharmacists are engaged in a small group education programme which meets regularly to discuss new evidence and to work through cases and examine comparative feedback on prescribing lab testing etc.  These groups have been operating successfully for more than a decade.

I chose the title because I thought it may be interesting for younger (and older) doctors to reflect on all of the expectations on them from patients, from peers, from funders and regulators, from politicians, from industry and not least from their families and friends. It can seem overwhelming at times and keeping a work life balance is all important, but easy to lose sight of.

In particular, the additional responsibilities that each doctor takes on above and beyond those set down by the system are I think worthy both of personal reflection and of wider debate.  Where can we individually and collectively make the biggest difference to improve the health of our patients and achieve a rewarding and enjoyable life for ourselves and our loved ones?  Not sure I have all the answers but there should be scope for some lively debate.

Thank you once again for the invitation and I look forward to all your questions.

Les Toop

Hi again Les, many thanks for your reply. Following on from your reply, I have a few more questions.  

– Comparing to when you started out working as a GP, do you feel GP trainees today have different priorities (for example, wanting to work less hours and wanting to have more time for personal activities)? Do most trainees in NZ choose the field because they believe in it or because they believe it is more “family life”-friendly? Is General Practice in NZ seen as an “easy” specialty? Since you say that around 50% of GP’s trained elsewhere, do you find overseas GP’s more motivated than native NZ GP’s? What is the main motivation behind such high levels of high medical immigration?

– With such a dominance of hospital medicine in the undergraduate curriculum in most universities around the world, which “tricks” do you recommend using when teaching to try to allure and motivate already under-motivated students to the world of primary care?

– Are there any particularities about General Practice in New Zealand that are overlooked or little known around the world, namely prevalent problems, implications of geographic isolation, research work and scientific activity, etc… ?

– You head a department of General Practice and Public Health. Do GP trainees carry out any sort of Public Health training during their vocational training? If so, do you feel it is important? What is the relationship like, in New Zealand, between GP and Public Health professionals? Is there a lot of joint collaboration?

– is there a lot of scientific and professional exchange with Australia? 

Many thanks again, and look forward to your reply. Best wishes, Tiago

I am hesitant to speak on behalf of my younger colleagues; most of my contact is with medical students who work much harder than we did at the same stage!  I believe in general that expectations of young doctors and their families are more realistic than ours were in the 1970s where some of the working conditions were terrible. 

I am sure that some doctors choose working in General Practice in New Zealand (especially in urban as opposed to rural areas) because it allows more choice over how their work is organised, how many hours and days and there is complete freedom to explore special interests that many general practitioners now pursue for example sports medicine, palliative care, travel medicine, minor surgery, musculoskeletal medicine etc.

I think many medical students choose to avoid a career in general practice as they see it as too difficult rather than an easy option. The breadth and depth of knowledge required for a general practitioner far exceeds that of most in hospital specialties. There are still income disparities between primary care work and those of interventional specialties.

The reason for the immigration is two fold.  Historically New Zealand has not trained sufficient doctors to replace those retiring. New Zealand is very dispersed with only just over 4 million people in a country the size of the UK.  Many overseas doctors see New Zealand as an excellent place to work, it is safe (recently voted safest country in the world) beautiful scenery (watch the lord of the rings trilogy to see the expansive scenery), an excellent lifestyle and highly organised first world medicine.  Many GPs visit for a working holiday and stay.

In Christchurch where I work, all of the doctors collectively own a well equipped after hours facility which means we only have to work there on call for approximately 6 hours every month.  Prior to this collective arrangement (now 20 years old) we all worked for up to 40 hours on call each week for our own patients.  Interestingly, the proportion of overseas doctors in rural areas is much greater than in the urban towns.

I think the only way to attract aspiring doctors to primary care is for them to work there for some part of every year in their training. Our final year medical students often come back from their residential rural general practice attachments enthusiastic and report it as the best clinical experience of their entire undergraduate course.  It is all about role modelling – put students in the care of young and enthusiastic GPs who enjoy their work and their lifestyle and they will want to do the same.

There are many things about NZ that are probably unknown.  General Practice for 15 years has organised itself and has a powerful say in the way health care is delivered, this is increasing with a move of previous secondary care back into primary care.  NZ doctors have worked very closely with practice nurses for three decades and there is a level of interdisciplinary work that would be unusual in most countries.  New Zealand has a very important indigenous culture.  Something few know is that NZ has a no fault accident compensation scheme which means the state covers care and costs of accidents including medical accidents.  There is no automatic right to sue doctors. This has the dual benefit of removing the need to practice defensive medicine (In my 30 year career I have never had to base a decision on avoiding a complaint or error) Also medical indemnity fees are minimal!

Unfortunately, as in other countries there are significant health disparities for the indigenous population and Maori (and pacific Island peoples) health statistics lag behind those of the non Maori majority.  However there are strenuous efforts made to correct these with some significant gains in many areas. There is much to do especially with smoking in Maori and as you would expect health of minority groups is usually tied up with wider social and economic determinants of health.  New Zealanders are great innovators in both technology and in social policy, it certainly is not a boring place to live and work.

There are of course many other issues not least about defining the place of professionalism in the future clinician which I could expand on later perhaps?

You correctly see that we are a joint department.  I see public health and primary care as appropriately joined. My teaching blurs the boundaries.  All clinical thinking for an individual should be thought of in the context of population health.  Some of the dilemmas in the way that guidelines are drawn up and applied relates to the confusion of how to apply population data to individuals.  This needs to be made explicit to general practitioners both in training and afterwards.

In teaching, in research and in robust debate we (public Health and primary care) collaborate always.

Interestingly, there seems to be less collaboration with Australia than you might imagine. New Zealand system probably has more in common with the UK than to Australia although they are planning some changes to bring them up to New Zealand speed!  There is friendly rivalry with Australia.  However, when New Zealanders (Kiwis) travel they usually like to go much further than “across the ditch” to Australia. In time there will be greater economic and other ties with Australia.

In conclusion I have a challenge for your members. Try and put in one sentence what you see as your clinical role as a general practitioner. What is it that your patients should reasonably expect of you? (and what would you want of your own doctor?). The follow on is: What might stop me from providing that?

I will share mine a little later on.

Les

PS.: I am just off to lead a group discussion with a group of GPs that I have met with for a decade.  The topic is:  How can we recognise and manage the misuse of prescription medicines.

Dear Les,

In reply to you challenge, I see my clinical role as a GP as providing comprehensive, accessible and resolve-oriented care, and that meets international standards of care. 

From my short experience, I feel my patients expect that I am understanding, empathic, have time to listen to them, and that I am competent, even though some patients have non-realistic or skewed expectations.

What can stop me from doing that? Training gaps, lack of physical resources, and society’s scepticism towards general practice, lack of a strong “gatekeeping” role and easy and widespread access to private secondary care.

Best wishes, Tiago.

Excellent and thoughtful.  I like it very much.  I will wait for a few more before I share mine!

Les Toop

Dear Les,

Firstly, well done NZ, in holding Italy off! Here’s a few from questions from me:

– I was very impressed with the RNZCGP conference programme. You will be hosting “heavyweights” of international GP such as Dr Iona Heath and the colleagues from Canada who run the Therapeutics Education Collaboration/Therapeutics Initiative, which curiously have already been highly mentioned in our listserver. At the same time, I notice there is no pharmaceutical sponsorship, which is less usual in European conferences.  How does the organizing committee finance the event? Do GP trainees in NZ usually pay for this sort of Continuous Professional Development events from their own money, or do they have some sort of sponsorship and of what kind?

The local GPS subsidise the trainees.

– At the conference, there is a strong emphasis on clinical skills workshops, and there are very few lectures. Do you think this sort of workshops is the main attraction of a conference such as your NZ Royal College conference? Do you think it is the way to go?

Several of the workshops will be run as small group education sessions similar to the one I sent you. We believe G Ps learn best from their peers and by group discussion.

– From what I’ve read so far, I assume that drug reps are not welcome in your department. In your opinion, should doctors see drug reps? If not, why? 

If there are good independent sources of information I see no reason for GPs to see reps .  I haven’t seen one for more than a decade and I don’t miss it one bit!  It is also insulting to think GPs cannot afford to buy their own lunch!

– What independent drug bulletins are there in NZ?

The ones we put out, our local hospital drug information site and BPAC NZ produces glossy magazine type drug info (not strictly bulletins).  There may be others around country but none sent nationally.

– Is there a list of required/recommended reading/study material for GP trainees in NZ or in your institution, or is it pretty much up to the trainee how to look for the preferential sources of information? If so, what does it include exactly (books, articles, e-learning, others?)? 

There is a definite curriculum for the trainees, which I think will be on the RNZCGP web site I will check and if it is not I will send it to you as an attachment.

– From one of the links you’ve sent, I’ve noticed further links to NZ GP journals. Can authors from overseas, say from countries like Portugal, submit to the main GP journals in NZ? Do you receive a lot of overseas submissions in NZ journals?

Absolutely The newly formed Journal of family Practice is always keen on overseas contributions. The editor is Felicity Goodyear-Smith   e mail f.goodyear-smith@auckland.ac.nz

– I found the educational materials you’ve sent pretty amazing. It says the pre-reading was prepared by “the Education Team”. Who belongs to the Education Team? Is it GP’s working full time in clinical activities? What is the methodology underlying the preparation of these documents?  

The education team is made up of a group of part time GPs, Nurses, Pharmacists and analysts,  I am the clinical leader and there are around 50 small group leaders who run their groups and are from time to time involved in preparation. Three of us from the Department myself, Dee Mangin and Ben Hudson are closely involved. The clinical governance of the programme is by the clinical practice education committee (CPEC) which I chair.  There are several packages prepared each year with about a 6 – 8 week overlapping preparation time.  A series of meetings are held with clinical input, literature searching, including reviewing all of the major English guideline groups here and overseas, critical appraisal, and utilisation review and topic preparation.  We have been doing it for 15 Years so it is a pretty well oiled machine   This method generates buy in form everyone and a large number of people eventually become involved and by doing so begin to understand the strengths and limitations of published evidence.  The final tweaking is done following a dress rehearsal of the session attended by all small leaders (with a combined clinical wisdom of more than a thousand years!)

– You mentioned the NZ bid for WONCA 2016, which was won by Brasil, with Australia being the runner-up. Do you think that the size/influence of the country matters when it’s about these GP political decisions (Brazil and Australia are both huge countries)?

No, I think it was home town advantage, the vote being in South (well central) America!! (just joking well done Brazil look forward to coming). Here is the link to the RNZCGP curriculum document. I gather a new interactive website is in construction http://www.rnzcgp.org.nz/curriculum/ Cheers, Les

Hi Les, I have one last question before we call it a day.

In your view, and internationally speaking, do you think there should be a minimum portfolio of technical procedures that GP’s should master in order to provide proper comprehensive care? As you know, and for a number of reasons, GP’s vary widely across different countries in terms of performing technical procedures at the practice. But nevertheless, should there be a “minimum” portfolio that would comply with international standards of care (if they exist)? By the way, the leading countries in GP, NZ included, all have their own set of guidelines and well-oiled to develop them (the NZ Guidelines Group is pretty well-known). But should there be international standards of care in GP? Who should establish them and how? Many thanks. Best wishes, Tiago

Hi

I think such a list would be difficult to construct.  By technical skills do you mean procedures?  You could argue that appropriate and up to date resuscitation skills would be expected and the ability to inject, remove skin lesions etc would be useful in most countries but not necessarily compulsory.  I remember reading somewhere a cross country comparison of the kinds of procedures performed by family doctors in different countries.  There was not too much overlap beyond the obvious.  Also if you work in a team it may be that certain technical procedures will be carried out by non physicians e.g. venepuncture. Suturing applying dressings etc (which would be done mostly by nurses here but maybe by Doctors in other countries). 

Even something as core as communication skills have cultural variations that mean learning in one country may not equip a GP for all countries.

International standards of care sound attractive but would be tricky.  How for instance would you gain consensus on the management of something a s simple as otitis media in two countries like the US vs the Netherlands or Scandinavia  Can you imagine trying to gain international consensus on the use of psychiatric drugs or statins fro primary prevention?

As you will have gathered from my previous posts I am no great fan of guidelines, think of them rather ads providing guidance at a particular point in time.  They often lack the patient choice element and there is a risk they become eminence rather than evidence based unless the group putting them together are mostly users rather than experts in the field.  

Think of working in General Practice as sailing ain a boat with your patients on a sea of uncertainty surrounded by islands of evidence from which you have to infer, extrapolate and deduce wise advice for your patient most of whom would be excluded from the trials that provide the evidence. Sometimes what looks like an island (of evidence) is actually an iceberg, cold, most of it is unseen, it moves around and is a hazard to traffic.  The half life of “truth” encapsulated in guidelines is often very short and beware of those more than a year or two old.

QUESTIONS FROM LUÍS FILIPE CAVADAS 

1 – When I read your explanation about the title that you chose “Defining the individual and collective responsibilities of the future Family Doctor” I understood what you said, but I would like know a little more… for example:

How do you perceive that in New Zealand the GP trainees and GP’s know and define in fact those responsibilities?

 It might be helpful to think of the responsibilities in two ways.  There are those responsibilities that are explicit and apply to all doctors and relate to rules, regulations and laws.  Also patients expect that we as professionals will be polite, that we will respect their confidentiality and that we will act in their best interests There are other traditional responsibilities of professionals that we may take on variably, these include looking after the poorest and most disadvantaged and when necessary resisting external influence on behalf of our patients.

There are also those expectations that are optional that doctors can choose to accept or not. You will all know colleagues who do and those who do not accept these (self imposed) responsibilities These include providing leadership and education to peers and to mentoring the next generation of colleagues, to work to improve the system through lobbing policymakers and politicians, to work with national professional bodies, to advocate, sometimes to disagree with the status quo or to new developments.  There are similarly choices to be made about how much to question what we are told as accepted wisdom, to be sceptical and questioning of what we are told from those with vested interest (and sometimes this includes those creating guidelines).  You could all add to this list I am sure. 

Young  (and old) doctors have to decide how many from the optional list they can take on while still meeting their own expectations of time to maintain outside (non medical) interests and to devote sufficient time to their families and friends, this can be a very difficult balance to maintain.

How do you perceive the same regarding other countries?

 I suspect the issues are the same in most countries but the medical culture varies, with some valuing the traditional professional values I have described while others have abandoned some or all of them. Be interested to hear how many of these issues are debated in Portugal. There was a series in the BMJ some years ago called core values in General Practice that Mike Pringle edited which may be worth a look.

Are the individual and collective responsibilities of GP’s really well defined, or is there a lot of indefiniteness worldwide.

 I think the first list is mostly known or is available in official documents although it can take a while to learn it all.  The optional extras of professionalism should be covered in vocational training and professional development teaching.

I think the optional (and to my mind more important list) responsibilities we individually and collectively choose to take on in working to improve the system and in resisting developments that may be of net harm to our patients (for instance over medicalisation) are ill defined and often not discussed.  This is why I believe it is worth discussing these issues with colleagues.  It is helpful I believe for younger doctors to plan out their careers and decide what the priorities will be at different stages. To try and do everything at once is a recipe for personal burn out and is unfair on our families.  Doctors are notoriously bad at driving themselves too hard.  Thee is a big difference between what one person could do and what they reasonably should do at any one time. Some of us never learn this lesson!  

Are defined responsibilities difficult to get? If so, why?

As above.

You showed that the GP’s and the nurse’s tasks are done harmoniously. In the UK, this is a controversial issue, unlike other countries like Portugal. What you think about this?

 I am not entirely sure what you mean.  It is my observation that when everyone is busy, collaboration is seen as a positive.  In contrast in areas where there are too many doctors for the available work, collaboration is seen as negative and competition occurs.

 I have no doubt that doctors, nurses, pharmacists and others working collaboratively together is much better for everyone especially for our patients.  True collaboration is however difficult as it requires a high level of contact and communication.  Shared clinical records and registration of patients with multidisciplinary teams make it easier.

2 – Your presentation is very interesting and important.

About the promotion of clinical practice supported by evidence and clinical research community I would like that you explain more this topic. How you do this. You give lectures? What are the most important topics for you in the EBM and about GP research…? You do develop many research works? The topics of that research works? Publications…Collaborative research works?

I am involved in teaching undergraduates and trainees and about how to use evidence to inform their interactions with patients.  I tend to concentrate on the grey areas of uncertainty and to teach on how to look critically at evidence.

We have a well-developed small group education system which involves groups of doctors nurses and pharmacists discussing recent evidence, working through clinical cases and discussing their own feedback with colleagues.  There are several weeks of preparation for each topic with a back to basics review of evidence.  As examples in recent months we have covered appropriate use of atypical antipsychotics, polypharmacy in the elderly, misuse of prescription medicines appropriate use of laboratory tests etc.   

Our research is mostly clinical and is designed to provide practical advice on how to manage common conditions and answer difficult questions in general practice.  We have had a theme to do with antibiotic resistance, urinary tract infection, smoking cessation, RCTs of various common infections such as cellulitis, pneumonia UTI.  We are half way through an RCT of antidepressant withdrawal etc.  We work with a number of other disciplines, which is very rewarding.  Medline or Google scholar will show many of the things I have been involved with.

3 – Could you please describe a typical workweek of a GP in NZ? How about the work week of a GP trainee?

A typical work for a full time GP would involve seeing patients at 10 – 55 minute intervals for three to four hours in the morning and similar in afternoon, often finishing with some minor surgery. There may be one or two house calls per day.  There will be one to two hours of patient and practice related paperwork to do each day.  On one or two evenings per week there will be a 1 -2 hour educational event as I described above.  Many GPs are involved in committees that meet early morning, lunchtimes or in evenings to plan system changes or develop better pathways with hospital clinicians.  Many GPs take a half-day a week off for recreation.  GPs living in the bigger centres are on call infrequently (once or twice a month) rural doctors are on call much more, many of these work extremely long hours and recruitment or locums and replacements to rural towns can be difficult.

Trainees in the official programme work in a supervised placement for four days per week with one day of block work with a set curriculum.  They would see between 12 – 20 patients a day and have regular tutorials with their host, they are on call occasionally.  It is a very supportive place to learn, in the second half of their intensive year they are studying for an examination. 

Happy to expand on any of the above.

Cheers, Les

QUESTIONS FROM BRUNO HELENO

Dear Prof. Les, 

Thank you for this e-conference. I found this paragraph very interesting:

All clinical thinking for an individual should be thought of in the context of population health. Some of the dilemmas in the way that guidelines are drawn up and applied relates to the confusion of how to apply population data to individuals. This needs to be made explicit to general practitioners both in training and afterwards .

Could you please expand on this idea? I’ve often been thinking in how can we reconcile a population perspective and and individual perspective in my own daily practice. One of the areas that has interested me in the last few years is preventive medicine (especially mass screening). However, I’m afraid that I’m not applying population data adequately to individuals. Sometimes, when i look at the population figures I think that an intervention is worthy, but when I try to translate that to individual risk it just doesn’t seem as meaningful. For example, one might say that breast cancer screening for 10 years would save 1500 lifes in Portugal (and this seems to be a reasonable), but to the women before me I could say that she has a 1:2000 chance of benefiting from it (if this decision was only based on figures, I would doubt that she would do it). Can you give us some pointers about the most common mistakes made when applying population data to individual patients? Can you send us some relevant literature on the subject?

As a conclusion I have a challenge for your members. Try and put in one sentence what you see as your clinical role as a general practitioner. What is it that your patients should reasonably expect of you (and what would you want of your own doctor). The follow on is what might stop me from providing that?

I would say that my clinical role is to cure the ill (or at least care for them), to help people stay healthy (and this includes avoiding to label healthy people with made up diseases), sometimes to provide confort during difficult times of their lives.

I think that patient should expect me to be up-to-date in my clinical knowledge and proficient in my clinical skills, to be sensitive to their preferences, to be easy to get to when they are acutely sick. They also should know about how some of my personal values have an influence on my clinical thinking.

Maybe the major hurdles may be:

1) After residency we don’t have to prove that our clinical knowledge stays up-to-date. Also, we are no longer formally assessed for our interview skills, or suture/infiltration/other basic procedures techniques. You only depend on yourself to stay proficient… And it’s so easy to start procrastinating things when you don’t have external pressure. This suddenly reminds me of the recertification discussion we had in this group a few months ago.

2) I never found a goldstandard to which I could compare if I’m sensitive enough to patient preferences. Maybe when we’re assessing videotaped visits, but I don’t get to do it that often.

3) It is just so dificult to know what bias you in your clinical thinking.

All the best, Bruno 

Dear Bruno.  First I apologise for missing your post.  You have identified what I consider a very important question for us all to consider.  Let me begin my answer by answering my own question “in one sentence” what do I see as my clinical role” I have thought about this a lot over the years and I found it helped to think what do I want of my GP when I am old?  Whatever that is, then I should try and provide that to all of my patients.

I see my role as providing evidence informed advice, wisdom  and treatment (which often required no intervention beyond that advice) upon which my patients can make informed choices, I then assist them to action those choices.

In doing so I try and explain the transient and ever changing  nature of current “evidence” and I assist them to make their own sense of the choices before them.

What makes it hard for me is accessing independent “evidence” when much of what is publicly available has been generated by industry and is incomplete as some (often on harms) has been suppressed by them. Putting the evidence into context for each patient and filing in the gaps where there is no evidence is both the challenge and the reward of General Practice.

Your example of mammography is an excellent one and some women do choose not to have one, I would argue that an informed discussion leading to a choice not to tale part in a screening programme is a positive outcome.  Indeed, our performance should be measured by having the informed discussions not on the actions that result, informed (and documented) inaction is an OK outcome.

I have cut and pasted the forward to our local preventive care manual which you might find interesting, I could send you the whole document which goes through the evidence for each preventive activity but don’t know about sending attachments to a list serve, Perhaps I will send it to Tiago and between you, you can decide whether to make it available to all.

Foreword.

In the decade since this manual was first published, preventive care delivered through general practice has been accorded much more importance and political priority. Some aspects now attract additional funding streams. As with the rest of medicine, the evidence base underpinning recommendations for preventive care is ever-changing, and further updates and revisions to recommendations are inevitable. 

It should be remembered that because many preventive interventions carry immediate or potential future harms, and are being imposed usually on people who are not unwell, evidenced for benefit and harms should be stronger than for the treatment of established disease. This applies particularly to population screening of the well population, where numbers needed to screen for one potential person to benefit often run into hundreds or thousands. In many instances, rigorous examination of the strength of the current evidence base for benefit compared to potential harm is insufficient to recommend population interventions. At times, this pits national screening guidelines against

the advice of those in influential positions who are convinced that the necessary evidence threshold has already been reached (prostate screening with PSA being an obvious example). On other occasions, recommendations from special interest groups or even official guidelines may anticipate evidence of benefit and safety which does not always materialise (HRT for post menopausal women being a recent example). It is well to remember when discussing options with those who may be tested or treated that evidence of a negative benefit to harm balance (e.g., HRT) is not the same as insufficient evidence of benefit being greater than risk (e.g., PSA testing).

In general, throughout this manual a conservative approach has been taken to recommendations in-line with the overarching philosophy of primum non nocere, first do no harm.

All discussions around preventive care should be informed by the best possible evidence of the time,

accepting that people (including clinicians) attach weight to potential risks and benefits differently, and they will not all come to the same decisions.

In reviewing material for this manual, scientific evidence, national guidelines, and guidance from many countries have been searched and reviewed, Where conflicting evidence or recommendations have been found, these are explained and wherever possible a common sense approach has been adopted Feedback is welcomed by the clinical education team at Pegasus, and where appropriate will be incorporated into subsequent revisions.

Les Toop

Clinical Leader Education November 2009

Another good example to consider is that of cardiovascular risk management (discussed in the manual above)   epidemiological data (in New Zealand we still use the outdated and known to be flawed Framinghan data set) have been used to direct how GPs treat their patients who might in the future have ischemic heart disease.

 Even if the risk equations were accurate (they are not) the way in which each individual understands such numerical risks are very different, some would see a 10% risk in the next five years as very high, some very low.  The danger is when GPs are encouraged (or even bribed as in the UK QOF) to start treatment at a completely arbitrary number that has been derived at national cost effectiveness level. In New Zealand our performance is to be judged by how many patients with a 15% 5 year absolute cardiovascular risk are on statins and blood pressure treatment. Given the biggest risk factor is age this risks over treating the elderly.

Thierry Christiaens from Belgium discussed it in the BMJ a few years ago and I have pasted a quote together with on e from the therapeutics initiative in Vancouver to start you off.

To use an absolute risk score as a threshold for starting drugs is dangerous and is not evidence based”

“We have to fundamentally rethink how to use risk tables when making treatment decisions in practice, taking into consideration the medicalisation of healthy older people and the correct use of drugs.”

BMJ 28 June 2008 Christiaens T Cardiovascular Risk tables. Estimating risk is not the problem, using it to tailor treatment in individuals is  and “Our analysis suggests that lipid lowering statins should not be prescribed for true primary prevention in women of any age or for men over 69 years. High risk men aged 30-69 should be advised that about 50 patients need to be treated for 5 years to prevent one event.  Many men presented with this evidence do not choose to take a statin.”

Lancet Jan 20 2007 – Abramson J & Wright JM Are evidence based guidelines evidence-based? 

I realise this had been a long post so I will stop.

As another task, consider an elderly patient say in their 80s who ends up in hospital with a  possible TIA (mini stroke) if the guidelines are followed they will likely be offered a statin, aspirin, dipyridamole and a blood pressure lowering agent at least. Imagine the patient comes back to see you the following week in your surgery and asks you “are all these new pills necessary they are making me feel sick and achy?”.  What will you tell them about the relative efficacy and potential harms of each of these medicines in preventing further TIAs or strokes?  Where would you find out?   Would you want to know if you were that 80 year old?

Bruno I like your insightful comments about the hurdles, I would say that he best way to address these is to discuss clinical cases and new evidence with groups of your peers, there will be variation in your views and in your practice, discussing that variation usually reduces it for everyone, If you also look and discuss your activity (for instance your prescribing and lab testing) compared to your peers you will find it surprising and helpful, This we have been doing in Christchurch for 15 years and GPs really enjoy it. Our education team provides the summaries of evidence, the cases to discuss and the feedback data on what we do, I could send you an example if you wish

Les

 TIAGO VILLANUEVA | LUÍS FILIPE CAVADAS | BRUNO HELENO | GUILHERME MENDES | JUAN GÉRVAS | GEMA PONCE | LILIANA LARANJO | ANA LUÍSA NEVES 

QUESTIONS FROM GUILHERME MENDES

Dear Guilherme,

Thanks for your questions.

To start with your last question first:    direct to consumer advertising (DTCA) has been and remains a major problem in New Zealand.  I, and my partner Dee Mangin (was Richards), have been campaigning for years to have it abolished, Unfortunately the current government does not see a problem with it.  If you follow this link you can read about our efforts on the university website http://search.otago.ac.nz/search?q=dtca&output=xml_no_dtd&client=uoc&site=uoc&proxystylesheet=uoc&numgm=5 look in particular to the pdf “for health or for profit” which is the most comprehensive NZ text on the problems. (Have a look at the case study on Vioxx some years written before it was withdrawn!  We also wrote a piece for the BMJ a couple of years ago on the dangers for Europe of going down the same path which you can find here: http://www.bmj.com/cgi/content/extract/335/7622/694 if you are interested to read more from a European perspective read the UK parliamentary Health committee report on the influence of the pharmaceutical industry athttp://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf To return to your questions.  Being a  rural doctor certainly requires maintaining many of the skills we as urban doctors use less often.  I cannot do the topic justice in a few words but you may like to look here http://www.rgpn.org.nz/ .  

The rural doctors in New Zealand have their own very active network. Almost no NZ GPs deliver babies any more following a bad piece of policy decades ago aimed to save money that effectively sidelined doctors (who were performing 50% of all deliveries  until the mid to late 80s) in favour of independent midwives.  The damage caused by this misguided policy are only now becoming evident and at last there are moves to return to a more collaborative working relationship between GPs and midwives.  

CME varies from traditional (Specialist lecturing GPs) to the small group learning experience I have described we have set up in Christchurch.  In addition, there are postgrad diplomas in things like musculoskeletal and sports medicine, travel medicine, appearance medicine etc. There are also various intensive CME periods associated with conferences. If anyone is contemplating a trip to NZ we are hosting the annual conference here in Septemberhttp://www.rnzcgp.org.nz/rnzcgp-conference-2010-registrations-now-open/ . If any of you were at Wonca in Mexico you would have seen us (Along with the Australians) coming a poor third to the Brazilian bid for the 2016 Wonca, well done!

Primary care research in NZ is good for the size of the country but as everywhere funding is a problem.  We do not do any drug company research which makes funding scarcer. I have described the clinical research we do.  For interest I have pasted the conflict of interest statement form our website below. Auckland is the biggest city in New Zealand and Bruce Arroll’s unit are very productive as is Tony Dowell in Wellington  (check Google scholar or pubmed).

Conflict of Interest Policy from our website:

The Department of Public Health and General Practice is committed to teaching and research that will promote medical and public health practice in the best interests of patients and the wider community.

1. Teaching. We believe that education should be based on the best available evidence for the public interest rather than advertising or promotion for commercial gain.

Therefore, we do not accept any funding for undergraduate or postgraduate education from pharmaceutical companies or other outside institutions either directly or indirectly that may create a conflict of interest in our teaching. This includes lunches or other promotional ‘gifts’ and hospitality.

2. Research. We aim to conduct research which will provide sound evidence for rational medical and public health practice. We believe it is important that such research should be, and be seen to be, impartial.

Our research is free of any funding which may prejudice these goals. We accept no funding for research from pharmaceutical companies or other for-profit organisations either directly or indirectly (as ‘unrestricted educational grants’ or fellowships) that may create a conflict of interest in our research.

This doesn’t make us very popular!!

re iodine: I am not aware of any studies but I can ask  I imagine will be too soon to find out we have only fortified bread (other than that from salt) since 2009 from memory.  South Canterbury (near Christchurch) had a problem with goitres early last century but with the iodisation of salt and vegetables coming from all over it seems to have disappeared. 

Don’t despair as your patients get to know you and your views they will realise that when you say there is no diagnosis for many of their symptoms and pills may do more harm than good, that you are helping them not denying them needed treatment.  Many patients don’t actually want to take pills, they have been conditioned to think they need them. Part of our job is to help them understand when treatment really is needed, when it is not and when it will do more harm than good.  I relish the challenge.

You may be surprised that I look after several Brazilian patients (all of whom I really enjoy) when the older ones go home to visit they tell me they have lively discussions with their family and friends about why I give them so few pills and do  tests so little!

Hope that covers most of your questions

cheers, Les

 TIAGO VILLANUEVA | LUÍS FILIPE CAVADAS | BRUNO HELENO | GUILHERME MENDES | JUAN GÉRVAS | GEMA PONCE | LILIANA LARANJO | ANA LUÍSA NEVES 

QUESTIONS FROM JUAN GÉRVAS

Dear Professor Les Top:

It is a pleasure to read your answers and comments to my Portuguese colleagues. Just to know a little more, perhaps you can take into account my questions:

1/ Computarisation is close to 100% in NZ, but what that means? Are you talking about electronic medical record? Are these records helping in applying EBM just in time? Are compatible different electronic systems? What happens when a patient moves with his/er electronic medical record? Are the electronic use for connecting with the pharmacists directly, for e-prescriptions? Are the electronic medical records an evaluation tool helping in quality assurance?

2/ How are you paid, and what is the total amount after taxation? Do you have a patient list (a practice list)? Are you pay by capitation? Are there P4P incentives? Are there young GP salaried by GP principals?

3/ May patients access directly to specialists? How specialists care is organized and how are the relationship in between GP and specialists?

4/ Do you work mainly in solo practice or group practice? In the second case, what is the usual number of GP per healht centre?

5/ If one terminal patient decide to dye at home, how is the provision of services organize? How the GP offers continuity of care in this case?

Thanks a lot in advance.

Juan Gérvas, MD, PhD, Spanish rural general practitioner until January -now a pensioner, Professor of Primary Care (International Health) and Public Health, Shcool of Public Health and School of Medicine, Madrid, Spain. www.equipocesca.org 

Dear Juan thank you for your questions If I read your signature correctly I hope you are enjoying your retirement from practice I imagine you are missing your patients?  (and they will be missing you also of course!)

1/ Computerisation is close to 100% in NZ, but what that means? Are you talking about electronic medical record?

Yes, full electronic records.

Are these records helping in applying EBM just in time?

Yes but it varies around the country there are privacy issues still to work through.

Are compatible different electronic systems?

Again variable in the city I work in 95% use the same system (which is far from perfect!

What happens when a patient moves with his/er electronic medical record?   

Depending on the two systems, either it is moved electronically or it is printed out and has to be re-entered which is very inconvenient, this issue might be solved if we move to a nationally consistent system, it is talked about (but not who would pay to convert everyone!).

Are the electronic use for connecting with the pharmacists directly, for e-prescriptions?

This is just beginning in some areas and is planned I favour a pull system from a shared repository as sometimes patients use different pharmacies. 

Are the electronic medical records an evaluation tool helping in quality assurance? 

Can be but as above there are still some privacy issues to work through,  We use existing data sets to provide QA feedback (e.g. we access national immunisation screening, prescribing and laboratory databases to provide comparative feedback.

2/ How are you paid, and what is the total amount after taxation? Do you have a patient list (a practice list)? Are you pay by capitation? 

Patients are enrolled so we have lists of around 1400 patients on average, up to  2000+ in some places.  Capitation payment is make up around 50% of income the rest comes from patients directly, from the accident compensation scheme and form other sources.  GPs work variably and so their incomes vary. A full time GP might expect to make anything from 150 to 300,000 New Zealand Dollars before tax which is 39 cents in the dollar (and a 15% GST) current exchange rate one NZ dollar equals about 70c US. 

Are there P4P incentives?

Only minor payments but still very controversial, have you seen the head to head debate in this weeks BMJ on QOF?  I with others have been a strong critic of P4P as I believe it to be anti professional and can lead to patients being coerced in to taking treatment which is of more “financial” benefit to their doctors that to themselves.

Are there young GP salaried by GP principals?

Yes and this is increasing.

3/ May patients access directly to specialists?

In general no they must be referred.  However, some specialists notably dermatologists ophthalmologists and obstetricians do not always follow the convention and will see directly.

How specialists care is organized and how are the relationship in between GP and specialists?

Specialists work in the public system which is both excellent and free/ Many (especially surgeons) also have private practice which is usually paid for by those patients who also have private medical insurance.  When people are very unwell they always use the free public system which has better, more comprehensive facilities than the private system.  Many specialist physicians see patients in private on one or two half days a week in their rooms, very few admit patients privately.  The relationship between GPs and specialists is in general excellent.  General Practitioners as a group are much more organized than specialists and take the initiative with innovation.

4/ Do you work mainly in solo practice or group practice? In the second case, what is the usual number of GP per healht centre?

There are a few solo practitioners but they are decreasing. In Christchurch the commonest number would be 3 or 4 together a few have 10 or more.

5/ If one terminal patient decide to dye at home, how is the provision of services organize? How the GP offers continuity of care in this case?

This is variable, many GPs (myself included would give the families of terminally ill patients their cell phone numbers and provide full terminal care. There are state funded palliative care nurses who can assist.  The after-hours system (which we run ourselves) will cover if he doctor is not available.

Dear Les:

Very clear and direct answers. Thanks a lot. According to my calculations, your income is around 5,000 euros per month after taxation. Not to much comparing with Germany, but almost double of Spain (we have also capitation, and list of patients, but the capitation income represent only 10% of the total income, mainly a salary as public employees working in public premises). Incindentaly, I am also againts P4P (and againts GPwSIhttp://www.equipocesca.org/wp-content/uploads/2009/04/gpwsi-2007-book.pdf http://www.equipocesca.org/wp-content/uploads/2009/04/innovation-2007-bjgp.pdf ).

Yes, I follow BMJ and the debate on QOF. Yes, I miss my patients and they miss me. But now I have more time for the students! Yes, NZ is one of the best-beautiful countries I have visited (I fully agree with your bias!).

Sincerely, Juan Gérvas

QUESTIONS FROM GEMA PONCE

Dear Professor,

Thank you for sharing your thougts wiht us. I would like to ask you something really simple: is there a lack of GP´S in NZ? In your opinion which are the best and the worst things around working as a GP in NZ ?

Thank you ! Gema

Hello Gema. Yes there is a shortage of GPs in New Zealand especially in the rural areas and small towns.  There are many GPS over 50 years of age who will retire in the next ten years and not enough younger GPs to replace them; this is of great concern to planners and doctors alike.  The situation for hospital doctors and for nurses is similar.  We are starting to train more but it will not be enough so we will be looking at alternatives such as physician assistants, nurse practitioners etc.  

Excuse my bias but New Zealand must be one of the best places in the world to be a GP.  The country is beautiful, the people are wonderful and still the public trust doctors and nurses. It is now well paid (it wasn’t ten years ago) and there is still much autonomy (the ability to choose how hard you work and what special interests you wish to pursue).

One sign of a good system is how old people are when they retire.  Many GPs here work on into their 70s as they like it so much.

It is never dull and things change rapidly and often in New Zealand.  (Did you know it was the first country in the world where women could vote?)

The things doctors dislike is needless paperwork and  we have been through a decade where doctors and GPs in particular have not been trusted by politicians and policy makers .  Many doctors believe there is too much central control of the patient doctor consultation and we have the beginnings of a pay for performance scheme (like the UK QOF but without the money).  This  tension that has yet to play out and there is both resistance from some (myself included) and passive acceptance by others.       

cheers, Les

PS.: Did you all notice New Zealand scored its first ever soccer world cup point by drawing with Slovakia in South Africa? The whole country is ecstatic as traditionally Rugby is the national sport. 

Hello Professor Les. Thank you for your answer.

As I was reading your answer i noticed lots of common things with Portugal, shortage of doctors, GP´S on 50´s and so on. But i felt really happy to see that the GPS there works till 70. I don’t think here is common. We have a big problem here with GPs finish working sooner than 60s ! That means something goes wrong… where is the secret for happily working till 70´s??

I would like to ask you wich is the role of a physician assistant in NZ. Are they trained in the University? It´s a kind of nurse? a kind of office employer? I´m interested in these as soon as i´ve listen to different new jobs in health lately as in Mozambique, where they teach “smallparts” of medicine in 2-3 years to youngsters and sent them to remote places. For example: training in abdominal surgery. training in deliverance and pregnancy. Medicine world professions are changing fast, and i have the feeling that GP´s are no alert to that… what´s your opinion about that?

I would like to answer your questions.

1/ role: resolve health problems.

2/ expectation: help to resolve health problems and tips to continue being healthy. Sometimes i think people expects to find a “superhuman” when they call in, and sometimes they feel desapointed when they see we are just humans.

3/ stop not doing that: NOTHING! the burocratical affairs and similars could make me go slower, but even snails arrive there.

Thank you!

ps: hope you do better in football than my country (Spain) did yesterday! congrats for your first worldcup

Professor Les, could you tell us how is the timestable in a GP´S practice in NZ? do you have work periods oriented to call your patients call/answer/comunicate with your fellows in hospital, urgency out of Health center? How many hours a day do you have “classic consultations” in an 8/h schudle for example?

THANKS. Gema

Most GPs would consult between 9 and 12 and between 2 and 6pm some start earlier and some work later.  Paperwork and phone calls are usually done before and after those times and over the lunch break.  Most GPs would see between 25 and 40 patients in a full day.  Many also look after rest homes for the elderly whom they will visit at lunchtime or in the evenings.  Many GPs have special interests where they may spend one or more half days per week doing something different.  On call can vary from 5 0r 6 hours every few weeks in a large town to almost continuous in isolated rural areas

The secret to happy working is I believe feeling that you have control over your work and being able to slow down and work with a group of patients you have known for decades which is both a pleasure and a privilege

Physician assistants do not yet exist in New Zealand although there are plans to start a programme.  I imagine it will be done in a hospital / university setting with community placements. The idea is that they help the doctor, working  under supervision but do not  work autonomously (As would a nurse practitioner) they have been in existence for a long time in the US and I think were first invented by the military.  Imagine if you could concentrate on seeing your patients, making clinical decisions and were relieved of the paperwork and ringing around to organise things!  I think done correctly it will be good thing.

I like your list.  I have found after 25 years my patients don’t expect me to be superhuman and they often ask if I am doing too much if I look tired, they look after me as much as I do them.

Next game is against Italy that could be a little harder!

Les Toop

Thanku Prof. Les.

I noticed lately that here in Portugal new GP´S are working more with portfolio jobs (you work in a Health Center, but also could do private practice, or work in an emergency room in a hospital, or be a consultant…), something that was not very common some time ago, and i think as long as you say is something similar there.

In your opinion : this kind of practice is good for doctors? is good for National Health Systems?

I think that you´re patients are really cute ones. :O). Caring the care giver is something good for society.

Hope you do nicely with Italy !

Hi Gema sorry missed your question.

I think it can be useful for full time GPs to have an another interest, be it an academic job or working in a particular discipline in hospital (I have a GP friend who scuba dives for instance who runs a decompression chamber for the hospital) Each department at our local hospital employs a part time GP as a Liaison or link person, they triage all of the referrals and provide a primary care perspective to the hospital clinicians, this works well.  We all work at our after hours surgery which sees many patients similar to an ED (we have X rays pathology and fracture clinics etc. As it is a cooperative it complements rather than competes with daytime general practice.

I think GPS bringing a primary care perspective into hospital is a good thing and if working one or two tenths doing something different helps prevent burn out and allows GPs to work on until they are older that is probably a good thing for the heath system. It is a great shame when a fit and wise 60 year old retires before they are able to pass on their knowledge, skills, attitudes and wisdom to the next generations, what do others think?

ITALY 1 NEW ZEALAND 1 the nation is VERY HAPPY (unless you live in Italy!) Good luck against Korea. What a coincidence that Portugal and Brazil ended up in the same group?   

cheers, Les

Hi Prof Les,

Thank u again for your answer and thankyou to put upsidedown our minds: family practice in Portugal and Spain has really no proud talking about the hospital-health center relationship, its like a baby that looks at his bigbrother with envy, thread and proud, big prof come to health center to teach how to act what to do…. and i notice and some of us notice that sometimes they are wrong (too much intervention with no guidelines followup) and were are right. We have something to say to them, and in NZ YOU SAY!

i´m really happy about that, if you dont stop saying good things of your country i m gonna start thinking moving to antipodes 🙂

(by the way i know there´s a great spanish bar in Christchurc :))

by the way congrats of your 1-1 NZ-Italy

Gema

QUESTIONS FROM LILIANA LARANJO

 Dear Professor Les Toop,

Thank you very much for your active participation in this virtual conference, which it’s being very interesting. I would like to ask you the following questions:

1. Which processes do foreign GPs have to undertake to be able to work in NZ (for example, Portuguese GPs)? Is it hard?

2. Are there any personal health records in use there in NZ? Is it common?

3. Do GPs working in rural areas of NZ get to do some surgical procedures? Or is there always a hospital nearby for the urgent situations?

4. Is there aditional training available for becoming a GP with a special interest (for example in Dermatology), like it happens in the UK?

Best regards,

Liliana Laranjo

 

Hello Liliana

Many overseas doctors work here and the procedure is not too onerous especially for short term work.

Here are the medical council regulations:http://www.mcnz.org.nz/Registration/Howtobecomearegistereddoctor/tabid/71/Default.aspx

There are a number of (mostly commercial) organisations offering personalised  (patient accessible) medical / health records, they aren’t particularly popular yet. There is much discussion about unified electronic records with pass-worded patient access. This will be some years off I suspect.

In rural areas many GPs will be involved in minor surgical procedures. Some GPs work in small hospitals and there is a diploma run from my University which provides additional training for such positions, details can be found here:http://www.otago.ac.nz/courses/qualifications/pgdiprphp.html

There is additional training available in some things like musculoskeletal medicine, anaesthesia, travel, tropical and migrant medicine, sexually transmitted diseases, occupational medicine etc. The two Universities offering these are the University of Otago and the University of Auckland both of which you can find via Google. In addition, there are various shorter courses to up skill in specific areas e.g. skin cancer excisions etc.

 hope this answers your questions. Cheers Les

COMMENT FROM ANA LUÍSA NEVES

Professor Les Trop,

It’s quite an honour to have you with – thank you for sharing your ideas, and also for posing such interesting questions. I was reading your email about the physician assistants and I completely agree with you.

I am know in the 3rd year of the family medicine residency in Portugal, but I am now doing a international clerkship in Boston, an I was quite amazed observing their work. In fact, medical assistants (MA’s) work under supervision here, but they are quite autonomous – they are the first contact of the patient with medical care, check the vitals, take blood for bloodwork, refill prescriptions, provide health counselling, prepare and dinamize group sessions for risk groups such as diabetic or hypertensive patients, and are a great help about paperwork (which is a major problem here, because of the insurance companies issues). They also play a role as gatekeepers, which I find to be really important.

They take care of many the work that we usually do in Portugal, and so the physicians may be more focused in observing patients and making clinical decisions.

I definelely agree with you that their existence can really improve health care – I hope the program starts soon there in New Zealand, and wish we had them someday in Portugal too. We can always learn something interesting with any health system, despite of the flaws they all have. (And as they say, even a broken clock is right twice a day 🙂

Once again, thank you for this discussion!

Ana Luisa Neves, USF Camelias / Gaia

 

FINAL SPEECH FROM PROFESSOR LES TOOP

As this is my last day I would like to take the opportunity to thank You ad your colleagues for a series of enjoyable and interesting conversations.  I can see from the number of posts and my rudimentary understanding of your language that you have a vibrant and thoughtful group. Keep it up.  Remember the world is full of shock horror stories  to which eventually people become numb. It is easy to spend too much time on criticising the obviously flawed and wrong taking up time that could be used for developing new and positive initiatives.

As young practitioners it is your role and your privilege to lead the next generation of change, keeping the needs of your patient at the centre of your thoughts as you advocate for positive change in the system.  What we have shown in NZ is that when GPs unite and organise they are a powerful force for good.  .  Do not defer to specialist colleagues, they are much less organised and have much less in common with each other than do GPs.  My advice is take control of your own education and make up your own minds about the evidence.

I am happy for any of you to contact me in the future if you feel I could be of help. 

As I said to Tiago the other day probably the most useful thing I have to offer is advice and experience on how to set up multi level and multi faceted professionally led education programmes.  The keys to success are enthusiastic young doctors (and clearly you have lots of those) doctors who want to do the right thing and learn from their peers rather than from secondary care specialists, and who are willing to forgo the trinkets of PHARMA, access to data and of course a sympathetic or persuadable funder.

All the best,

Les

 

 

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