Criticism of GPs’ refusal to treat some infant patients in-person a ‘cheap shot’

Anastasia Tsirtsakis

15/03/2021 6:50:29 PM

Many GPs who ask that young patients be tested for COVID-19 before treating them in-person believe they are simply following state-issued health advice.

Concerned mum checking her child's temperature.
There are calls for infants with respiratory issues to be exempt from compulsory COVID-19 testing.

The matter was raised in the Victorian Parliament last week by Liberal Democratic MP David Limbrick, who called for GPs to see infants with respiratory symptoms – even if COVID-19 has not been ruled out.
‘For infants that are having respiratory issues, it seems clear to me that that should take priority over waiting for a COVID test with the current rates of low transmission that we’re seeing within the community,’ he told 9news.
‘This needs to be fixed because I’m worried that they’ll end up with a tragedy on their hands.’
But RACGP President Dr Karen Price says the MP’s commentary is ‘really disappointing’ and a ‘cheap shot’ at GPs.
‘[The MP’s] advice is not pandemic advice – it is not consistent with the [Victorian] Chief Health Officer,’ she told newsGP.
‘So, it’s really putting a big burden upon the whole community to make statements like that and that’s unfair to GPs.
‘We look after [infants] very carefully in general practice and we’ll examine them thoroughly. But given the state of PPE [personal protective equipment] and given the public health directive, unless you have a respiratory clinic with all the proper precautions, you can’t do that.’
Mr Limbrick’s comments follow a letter that was sent by Queensland Chief Health Officer Dr Jeanette Young, which encouraged GPs to see more patients face-to-face, including those with respiratory symptoms, following a rise in emergency department (ED) presentations.
According to current Victorian Department of Health guidance on respiratory support for children during the coronavirus pandemic, ‘most children presenting for respiratory support are considered suspected coronavirus (COVID-19) cases until proven otherwise’.
‘If you’re bringing someone like that into a normal waiting room, you’re going to have people who’ve just got over cancer or might be still in the middle of chemo, people who’ve got all the high-risk factors for COVID like obesity or hypertension, and so forth,’ Dr Price said.
‘Then if it proves to be positive, you’ve got to shut down your clinic to do proper cleaning. There’s a real logistical challenge.
‘We’ve just had a clear example in Queensland of a doctor being unprotected and catching COVID. So even though the risk is small, we practice a COVID-safe environment and we can’t make exceptions.
‘These people are not really involved in the health sector [and] they’re making large statements, but it’s problematic because they’re not understanding the health sector and what’s required.’
RACGP Victoria Chair Dr Anita Muñoz also believes it is ‘very unfortunate’ that GPs are being criticised for what they perceive is the appropriate clinical decision.
‘We’re existing in a state of emergency under which the directives of the Chief Health Officer are actually the law,’ she told newsGP.
‘GPs have been advised that every patient with any respiratory symptoms must first get a COVID test because that is the essential tenet via which we’re going to overcome this virus and this pandemic.
‘We also know that there’s been a call for particularly young children to get those COVID swabs done at paediatric-specific facilities because the experience is much less harrowing.’
Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), says general practice has a responsibility to first and foremost ensure that everyone – from the doctors to the practice staff and patients – is kept safe by managing infection control within their environment.
But he is not certain that a negative COVID test should be the sole deciding factor.
‘Negative COVID tests don’t mean you don’t have COVID,’ he told newsGP.
‘They’re not completely reliable … and I don’t believe should influence the decisions here. You can either provide a safe environment to see them or you have to make some other arrangement.’

RACGP President Dr Karen Price says many GPs are simply following directives set by their state’s Chief Health Officer.
Associate Professor Morgan advises that practices consider how they are set up – from the car park to the waiting room, to any after-hours services – in order to best cater to their most vulnerable patients.
‘A 24-hour delay in a young person with an acute respiratory illness could make the difference, if it turned out to be severe, between life and death,’ he said.
‘Parents of young babies with respiratory illnesses are quite right to be anxious, and those children need to be assessed in a safe way somewhere.
‘Where that can happen safely face-to-face in general practice, that’s fantastic. But each clinic has to have considered its own arrangements of what it can manage … to be able to provide that environment for safe assessment.
‘I don’t think it’s a reasonable system to have a blanket rule that says all people with respiratory illness go to an emergency department. The health system is not set up for that approach. But there are many different ways that GPs can set themselves up to provide a service for their patients.’
This can include, but is not limited to:

  • triaging patients appropriately prior to arrival
  • providing a separate waiting area for patients with respiratory symptoms, preferably outside or in the carpark
  • defining foot traffic through the practice using floor markings and signage
  • conducting in-person consultations for patients with respiratory symptoms at the end of the day
  • donning appropriate PPE
  • asking the patient and carer/parents in attendance to wear a surgical mask
  • ensuring that reception staff wear a surgical face mask if they are in contact with patients with suspected COVID-19
  • if possible, dedicating one room to consulting patients with respiratory symptoms. If not possible, cleaning the room as outlined in the RACGP COVID-19 infection-control principles.
 Professor Morgan also said some practices will not be able to safely treat patients with respiratory symptoms face-to-face.
‘Clinics have to actually look at how they’re set up to be able to do all of this and to make their own decisions as independent small businesses to work out how best to provide a safe environment for all patients,’ he said.  
While the vaccine rollout is underway, the majority of GPs have been classed as part of phase 1b and are yet to be vaccinated. Until that process is complete, Dr Muñoz says there could be individual factors for which patients are triaged to another service.
‘We need to remain rational. If a GP says, “I cannot see this person face-to-face”, it’s very likely that there’s a very good reason for that,’ she said.
‘One is following the orders of the state, the other is we have to recognise that GPs themselves have their own medical conditions to care for, and there’s also being able to ensure that if a person with respiratory symptoms is seen in clinic that that area can be cordoned off and kept away from the general public to keep them safe.
‘So, it is not a simple decision; it needs to be well thought out because if this was rushed or GPs started to ignore health directions from chief health officers, I’m sure that the criticism will be even more overt should something go wrong.’
And if the public health advice does change, Dr Price says GPs will require more support.
‘We’re in a pandemic, so public health responses really require public health support,’ she said.
‘General practice can’t keep carrying that all the time and PPE, fully supplied, would have made it possible for us to be able to see patients in those circumstances depending on our room sizes, and all of the other things.
‘If they change the directive, we will always rely on what the Chief Health Officer says, and that’s what we’ve been doing. We’ve been cooperating all the way through.’
Mr Limbrick’s comments have resulted in a barrage of negative press and comments, which Dr Price says has affected GPs. 
‘We’re somehow [seen as] part of the problem when actually we’re a huge part of the solution,’ she said.
‘We’ve been working really hard to keep all of our patients as safe as we possibly can and cooperate at every turn with the government.’ 
Dr Muñoz agrees that some of the public response has been ‘enormously disappointing’ and fails to recognise the ‘huge contribution’ general practice makes to the health of the nation.
‘It feeds into a trend, which I’m yet to understand, of attacking a part of the health system that I perceive people find easy to attack in order to gain political points, or to gain political attention,’ she said.
‘It’s the systematic spreading of misinformation that general practice is not effective or it’s not competent, and we actually know that the truth is completely the opposite.
‘I feel that it’s really an ethical issue that politicians who know not very much about the subject feel so confident that they can disparage general practice.
‘Why a politician would want to erode his or her own health system, and make it more difficult for patients to access care and make it more likely for patients to go into emergency departments, is really beyond my capacity to understand.’
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Dr Madhu Tamilarasan   16/03/2021 7:12:39 AM

Who is the audience for newsGP articles like this other than existing GPs?
I haven’t seen these responses to the criticism levelled at us in any mainstream paper/ news outlet.
There is no point writing articles and getting a college response to these issues to disseminate amongst members! These college responses need to be much more forcefully out for everyone else - politicians and Jo public - to see and understand.

Dr Christine Barstad   16/03/2021 7:13:50 AM

Excellent comprehensive article. I hope you sent a copy of this to all state and federal politicians!

Dr Antje Vogelsang - Sharman   16/03/2021 8:09:18 AM

excellent article? - to the wrong audience .... and in fact I think it IS important to have a blanket rule - because NOT having one, NOT sticking to one leads to the appearance that some surgeries will see patients, some wont - and this creates confusion and anger. ED is not set up for this - after over a year of time to organise/get the right set up ?????????? Again we are supposed to carry the risk - and the blame .... and the cost ....

Dr Primo Phillip Bentivegna   16/03/2021 8:24:30 AM

Excellent article, now can we get these messages out to the media and the public please? Internal discussions like this have minimal impact I'm afraid.

Dr Irandani Anandi Ranasinghe-Markus   16/03/2021 8:26:37 AM

Thank you Karen Price and Anita Muñoz for responding on our behalf. Totally agree you can not put a whole community at risk. Have been in this situations many times but worked around it by donning PPE taking stethescope, thermometer out to car, assessing there and making a call. Also took opportunity to swab for COVID and Resp panel and got RSV back! At least 3 cases of Bronchiolitis diagnosed in infants in past few months and needful done with relatively low risk to anyone. Please share your comments with the major newspapers as suggested by previous author.

Dr Jeanine Suzanne McMullan   16/03/2021 11:24:17 AM

You know what, I'm with the mum of the 3 year old who can't breathe with asthma and croup who is being told " GP says NO". Where is the public health care campaign for #rightcare#righttime#rightplace. Your GPs role in the Pandemic. It took me 5 click throughs on a bland SEMPHN website to establish there is only ONE GP respiratory clinic in David Limbrick's electorate BUT it does have appointments at 3pm today, What hope does the mum have of knowing to do this? Winter is coming...

A.Prof Christopher David Hogan   16/03/2021 11:56:14 AM

Err Letter writing Colleagues,
Who said this it the only audience for these statements?
Reinforcing such statements to politicians in our own words is a major contributor to the message getting thru.
So, have you sent an email/letter to your state & federal members about this?

Dr Jeanine Suzanne McMullan   16/03/2021 12:39:51 PM

My patients are talking to the local MPs. It's their voices and health care needs that count in this pandemic.
That mum of the 3 year old probably didn't even get a Medicare rebate for the GP telehealth appt. They'd not been seen since the 18m needles. (12m rule)So that's "GP SAYS NO" and $80 bill. This is not a vote winner for working families in anybody's book.

Dr Terence Brett Hunt   16/03/2021 3:46:32 PM

Mr Limbrick probably thinks that doctors have a duty to see patients. especially sick ones. How wrong he is! We can all hide behind the CHO. This is consistent: the pandemic has seen the rise of tele-health and doctors just refusing to see patients. All those regular visits are unnecessary after all! We've always had the option of rushing the kid with a rash into a side-room, but now we've modernized: "just go away!" I'd be ashamed to work in a practice that turns away sick people. Does this really mean that nobody with respiratory symptoms can go to the GP?

Dr Ian Mark Light   16/03/2021 4:42:02 PM

With zero community cases of Covid 19 the risk is very low but sure double mask surgical and cloth and the five dollar face shields plus gloves ought be donned and doffed .
A room with a window that allows fresh air in is also a plus but car park consultations if necessary yes .
Triage over the phone by the worried parent’s GP or the-practice GP available ought be organised and can be done .

Dr Paul Gerard Egan   16/03/2021 4:53:15 PM

gps should be reclassified from 1b status-we are front line healthworkers-the royal childrens hospital needs to give us guidelines on which kids with urtis we need to swab-i believe we are advised against swabbing kids with croup.
Respiratory clinics have done a good job but patients have trouble getting bookings.Video consult can be useful.,but i think eyeballing kids makes parents and gps more comfortable all round.

Dr Alice Helen Frampton   16/03/2021 8:48:10 PM

Thank you for responding to these thoughtless and ignorant comments, Anita and Karen.
The “GP’s are stupid” sentiment underlying many comments by politicians and journalists can really affect our morale, and we need this sort of prompt response and advocacy. Thank you.

Dr Catriona Moxham   17/03/2021 6:41:11 AM

Agree with above - gps have been silently getting on with the job and trying to keep themselves and their vulnerable community.
Given the risk that is described, what I don’t understand is why gps are not 1a in the rollout of the vaccine?
Even with insisting on a covid test, we agree that that only reduces the risk a bit- and that the consequences of us getting covid and serious for the community: so let’s get us vaccinated!!! 1b means not fully immune til mid years.......

Dr Catriona Moxham   17/03/2021 6:49:59 AM

And happy to start seeing patients with respiratory illnesses immediately before a covid test if vaccinated!! That would, I agree make the community safer

Dr Suresh Gareth Khirwadkar   20/03/2021 9:02:47 AM

And still almost zero mainstream media rebuttal from RACGP. The general public do not read newsGP. More and more newsGP just feels like a vanity project from RACGP and a way to pretend to the membership that it is doing media releases.

Dr Hilton Leslie Shapiro   20/03/2021 1:03:15 PM

I agree with most of the sentiments expressed above in relation to GPs being at the forefront of this pandemic and having to protect themselves their staff and other patients. I do believe,as many have commented the press, journalists, politicians and media in general, should be fully informed on this and there should be a campaign to promote these views. Come on RACGP let’s get some media advertising!!!!