‘There must be a better way’: Dealing with complex patients

Hester Wilson

31/08/2021 11:46:06 AM

Trying to manage these patients is stressful enough, but when the authorities get involved it can create a nightmare, writes Dr Hester Wilson.

Stressed woman at computer
Doctors often report being made to ‘feel like a criminal’ through the process of regulatory review.

The other day I was chatting to one of my GP colleagues, let’s call her Lucy, who had recently moved practices. I asked her how it was going and she said, ‘It’s a lot better now, but it was really hard’.  
When I asked her about this, she told me about a recent and very stressful process that she’d gone through with her state regulatory authorities and medical board.
I know Lucy to be a caring, hardworking GP. She worries about her patients and goes that extra mile to assist them to ensure good care.  
A relatively recent Australian graduate, she was working in a bulk-billing practice in a metropolitan area. The practice supported a large number of patients from low socioeconomic backgrounds. On starting at the practice, she inherited a number of patients on multiple high-risk medications – things like opioids, benzodiazepines and other sedatives.
Lucy was aware of the risks of these medications and that she needed to work with the patients to cut down the doses.
She found this process gruelling and struggled to get them on board: ‘They couldn’t or didn’t want to access physio or counselling, and they’d been seen by the local pain specialist who supported the high doses they were on.’
The patients would say, ‘But the specialist has told me this is okay. Why are you doing this?’
Lucy confirmed that she had received a number of letters from the local pain specialist supporting continued high doses of opioids, but the doses were indeed high by today’s standards – ie oxycodone 300–500 mg a day – and she struggled to rein them in.
She said it felt like a losing battle: ‘They were so anxious and upset and just couldn’t see another way to manage their pain.’
Lucy would refer the patients back to the pain specialist who would send them back to her on the same or even bigger doses. Either that or the patient just wouldn’t get to the appointment.
‘I was just overwhelmed,’ she told me. ‘My practice was busy, there never seemed to be enough time and each time I saw one of this group, I knew it was going to be a difficult consultation.’
My colleague discovered that she needed to apply for a state authority for this group of patients and so started this process, as she ‘wanted to do the right thing’.
Unfortunately, this resulted in the authority looking closely and critically at her practice, and they came down hard.
Lucy told me they made her ‘feel like a criminal’ and she was reported to the medical board. This started a process of review and, her medical defence team told her, a real risk that she would not be allowed to continue to practice.
She did more reading. She regretfully told the patients she could no longer prescribe for them. And by the time of her review at the medical board, Lucy had a much greater understanding of the issues and how to approach these tricky clinical situations.
The board review members commended her on her response to the process and her efforts to upskill and change her practice. They did not impose sanctions.
But how is Lucy today?
‘I still get stressed when I think about the process,’ she said.
‘I wish the regulatory staff had supported me, taken an educative approach. I was trying to do the right thing but was ignorant and overwhelmed.
‘Now I have to be careful and not take too much on. But where do patients with these complex needs get their care?’
I wonder the same. Where are they now? Does the whole rollercoaster continue with another GP?  
I do understand the need to protect patients from harm and that these high doses are risky, but there must be a better way that supports GPs who try to help patients who present with risky medicine use.
One that doesn’t stigmatise either the patient or the doctor. One that supports the patient with good care. One that hears the patients concerns and their experience. One that understands that while addiction may be an issue, there is often a whole raft of complexity – mental health, past trauma, ongoing distress, poverty, physical illness that compounds everything.
An approach that understands that one practitioner cannot provide these patients with everything they need.
As it stands, we have a system that is poorly equipped to adequately assist people with multi-morbidity.
Just like it takes a village to raise a child, it takes accessible, patient-centred, multidisciplinary care to assist us in general practice and our patients to get the care that is needed.
And that, my friends, is still a dream.
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Dr Jennifer Joy Alexander   1/09/2021 8:51:22 AM

Brilliant article that sums up the very real issues succinctly. Thanks, Hester.

Dr Michael Charles Rice   1/09/2021 9:50:47 AM

...and what have the regulators done about the pain consultant?

Dr Richard Newton   1/09/2021 10:35:19 AM

That is a very difficult situation, but I can't see how Lucy could have been seen to be at fault. Did she involve her MDO? I had to deal with an AHPRA potential complaint recently - my MDO were very helpful, as in fact were AHPRA. Also very important for the practice owners or principals to be supporting Lucy in terms of their policies and procedures.

Dr Janaki Gharti-Magar   1/09/2021 1:16:18 PM

Thanks Hester, we GPs need support in dealing these type of situations.

Dr Cassandra Lea Steel   1/09/2021 4:40:34 PM

Could she share some of those resources she used to upskill please?
Got a few inherited patients like this myself and struggling with a particular one who’s making me constantly doubt myself.

Dr Hester Wilson   1/09/2021 6:46:12 PM

Hi Cassandra,
Thanks for your question. I will check in with "Lucy" and find out what she found most helpful. I'll check with the RACGP what is the best way to ensure the answers get to you.

Dr Pradeep Samarakoon   2/09/2021 1:47:23 PM

Lucy, why did you work in a bulk billing practice? Bulk billing practices are for IMGs to rot, and no one will bother to improve working conditions there. You could have easily started where you are now.

Dr Pradeep Samarakoon   2/09/2021 3:16:35 PM

Here are some questions for the RACGP and the readership.
Why did 'Lucy' have this experience at a bulk billing practice?
What about others working at the practice and other 'bulk billing' practices?
Is it that IMGs are better trained that they cope well in 'bulk billing' practices?
If this happened to an IMG will there be any one to offer their sympathy and even write their story or will it be looked upon as a weakness of the IMG?
Do IMGs feel they are adequately represented by the RACGP in their 'unique' issues or should the IMGs form their own association due to lack of representation form RACGP?
What has RACGP done to advocate improved working conditions at 'bulk billing' practices? Does the RACGP feel that they have done their job now that 'Lucy' has escaped the situation? Will the RACGP show that they are willing and find a way?

Dr Cyril Gabriel Fernandez   13/11/2021 7:42:18 AM

The concept of Family General Practice is very significant. Doctor Shopping of Opioids , Benzos, and other addictive medications which have chances of being misused will require a National Networked System, rather than patients having to carry with them hard copy of the script. eScript in the iCloud is a good option. This modus operandi will help minimise misuse of medications