I am a GP of 47 years and I have been working for almost twenty years in the most beautiful GP practice in the nicest village in Brabant with the nicest patients. I enjoy my consultation hours, I love my profession as a general practitioner, I have a good income and I am highly regarded by my patients. Although I really don’t want to hang up my stethoscope yet, I will soon stop as a practicing GP.
Why? Because the current organization of the GP profession means that I can no longer be a good GP. I would like to explain this to you.
Heavy office hours
First of all, my office hours. These have become a lot heavier. No, not because, as many people think, GPs must see more and more nonsense. The opposite is true. The GPs only see challenging, important problems during their consultations and that is why the content of my consultations has only become more fun. Very rarely do I see patients who I feel are ‘offending’.
The time when doctor’s assistants functioned as secretaries who merely filled the GP’s office hours are long gone. Our assistants are now very well trained and deal with more and more minor health ailments independently. From the flu to stuffy ears, they treat wounds, assess ear infections and reassure young parents who endure hard tropical nights because of their sick offspring.
Only when this does not work or there is more to it, do I look around the corner. I then get the impossible task of checking both the sick child carefully in ten minutes and also explaining to the parents that their child does not have a life-threatening illness, as their impression was after some googling.
This is a nice example of my nice GP work, but not in those damn ten minutes. But it could be much worse. I get twenty minutes for a bad news interview in which I get to hand out a death sentence and discuss future suffering. Twenty minutes for a slow, elderly patient who needs to get dressed and undressed for a physical examination and then also needs a little more time to understand my story. Twenty minutes for a patient who bursts out crying because he doesn’t feel like living anymore, and for whom I have to consult with the mental health crisis service (three transfers, waiting, waiting, no room for admission…) and also twenty minutes for a fun, challenging surgical procedure, which includes letting an anesthetic take effect and setting up and clearing the necessary materials.
Short consultations
Yes, because those are my two products that I have to offer as a general practitioner: ten and twenty minute consultations. This has been the case for decades, while the consultations have become many times more complex, the number of (self-employed) elderly is increasing, my patients ask for more and better explanations and my medical arsenal is growing.
These idiotically short consultations reduce the quality of general practice medicine. Because of this time pressure, I’m sending the surgical procedures to the hospital. Surgery is many times more expensive there, but it saves me at least thirty minutes. Instead of a good history and physical examination, I let patients take a blood sample. Instead of a reassuring chat about the abdominal pain, it becomes an ultrasound of the abdomen – for reassurance. This is very bad and expensive medicine, where I make fun of my patient and deny myself.
In addition, there is also less and less space for consultations. The time I need for meetings and organizing is already running out. And it becomes more and more. This is because I have to organize an incredible amount of more care for my patients. A gigantic mountain of care from hospitals, mental health institutions and old people’s homes has added to my plate.
Army supporters
Because of all these care tasks, I had to hire an army of practice nurses and other assistance: practice nurse diabetes, practice nurse asthma/COPD, practice nurse mental health, practice nurse elderly care, et cetera. They do a fantastic job, the quality of this care appears to be very high and the patient satisfaction is unprecedented. And last but not leastthis care is many times cheaper than in hospitals.
But the downside is that all these doctor’s assistants have to be supervised, assisted and have to deal with numerous questions about patients who do not fall within their protocol. In addition, they produce an enormous amount of data.
Dates, you will think?
Yes! One of the biggest mistakes made in the Netherlands is that health insurers are appointed to regulate our care. Insurers are audit offices and audit offices need a lot of data. They can’t live without it and love it. If you know what the healthcare costs, the director’s car and other overheads, you can calculate the healthcare premium. And, more importantly, you can then start to focus on budget cuts, which is desperately needed in our health care system. That is why we are endlessly busy producing an endless amount of data. However, this creates serious problems.
The costs of medication or a new artificial knee are relatively easy to calculate. But what does a stomach ache, good palliative care or, our most important ‘GP product’, a reassurance cost? The most important products supplied by a general practitioner cannot be calculated, let alone measured their quality.
back down
And yet it must. In fact, we have to negotiate about it with the health insurers. To this end, the GPs had to join the GP groups. These are therefore led and directed by general practitioners. GPs cannot say ‘no’ to their patients, and certainly cannot negotiate with commercial partners. So in these negotiations, my GP group backs down time and again.
This means that I have to compromise on the care of my patients again and again. Less time for our practice nurses, fewer check-ups for chronic illnesses and even interference with the prescription of medication. I often first have to try the cheap drug prescribed by the insurer, even though I know it won’t work for this specific patient.
It won’t be long before I have to say to my patient: ‘Sorry madam, but your health insurer pays our psychologist insufficiently and that is why you are no longer allowed to see our psychologist for your depression, but luckily we still do your diabetes. But unfortunately we have to regulate your diabetes with fewer blood tests and from now on you will receive inferior sugar pills that your health insurer has managed to negotiate cheaply with the pharmaceutical industry.’
Software Packages
Another problem with data is that it has to be produced by software. Every laboratory, hospital, mental health institution and digital care provider (yes, we must also try to treat your depression digitally from your health insurer) has different software packages. All this has to come together in my GP computer. You guessed it. The ICT costs are gigantic and the tons of man-hours to make this crazy funfair work, strangely enough, are not registered anywhere, let alone declared.
Many of my refresher courses are therefore no longer about medicine, but about how we can achieve this, as is also the case for protocolling, digitizing and organizing patient flows. We mainly do this outside office hours instead of playing tennis or putting the kids to bed. The ‘good’ news is that our physician registration committee considers these topics as important as, say, an ophthalmology course, so we get just as many retraining points for them.
Young generation
The new, young generation of general practitioners sees this and thanks for this. They do want to put their children to bed at night. And if they go for a refresher course at night, it should be on a meaningful subject that will keep them from being a good primary care physician or becoming an even better one.
As a result, there is a huge shortage of general practitioners who want to run their own practice. I understand them, but I find it a great pity that they often miss out on the most beautiful aspect of our profession. For me, that means building a long-term, in-depth relationship of trust with patients, so that as a general practitioner I understand my patients even better and can assess their health situation. In my opinion, only then can you practice the very best general practice medicine.
I am now going to end this relationship with my wonderful patients, and it hurts unimaginably.
Robbert Collignondedicated and passionate general practitioner.