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Opinion

Who are the pathology nudge letters really targeting?


Deborah Carrington


24/05/2022 5:00:59 PM

Rather than rogue doctors, these letters seem to have been sent largely to GPs who treat our most vulnerable patients, writes Deborah Carrington.

Female GP reading a nudge letter.
The most recent round of nudge letters was met with dismay by some in the general practice community.

Last week, the Department of Health sent out a new wave of ‘nudge’ letters.
 
We have been through this before. The announcement was met with a mixture of fear, anger and then – confusion. This time the letters were targeting, of all things, pathology requests.
 
Vitamin D, Iron studies, Thyroid function tests, Vitamin B12.
 
I have not received a letter personally, but this may only be due to being on maternity leave for some of the targeted period.
 
I do know that all GP registrars are taught early in their training about rational ordering of investigations. As a medical educator, this is one of the first lectures I deliver to our first term GP registrars.
 
We teach them about the need to reduce wasteful Medicare spending, the risk of increasing patient anxiety and the problem of finding incidentalomas. We teach them not to take a ‘scattergun’ approach to ordering tests.
 
In contrast, I would argue that these nudge letters are adopting a ‘scattergun’ approach to catching out GPs.
 
Though is it possible that a small number of practitioners out there are ordering large panels of tests without a clear clinical indication, I don’t think these recent nudge letters are targeting those GPs.
 
Judging from the response on social media, these letters seem to have been received largely by GPs who treat our most vulnerable and marginalised patients.
 
They have also been received predominantly by female doctors, which is maddening given that the tests being ‘nudged’ are legitimately required for so many women’s health consultations.
 
So, who are these wayward doctors who have received a warning this week about their clinical practice?
 
They are the GP who has weekly bulk-billed appointments for the teenage girl with an eating disorder. Each week they do their best to keep them out of hospital, spending hours calling multiple services and begging for someone – anyone – to help them.
 
They are the GP who sees multiple presentations a week of female patients with fatigue, low mood, menstrual irregularities and menopausal symptoms. Long, complex histories and patients with multiple layers of carer stress, COVID fatigue and no time for self-care.
 
They are the GP who cares for refugee patients, patiently taking broken histories with interpreters. They must screen for nutritional deficiencies whilst holding space for horrific stories of abuse and trauma.
 
They are the GP in an Aboriginal Health Service, doing their best to provide holistic and culturally safe care. It is hard to ask a patient to return for another blood test when they must travel long distances and overcome immense anxiety to attend appointments.
 
They are the GP in a rural town like mine, where birthing services have been suspended.
 
With the nearest maternity hospital 100 km away and most appointments via telehealth, GPs are often the only way these women have a regular physical examination. These vulnerable mothers need long antenatal appointments. In addition to low iron and Vitamin D, they carry realistic fears of hitting a kangaroo or giving birth on the side of the poorly maintained highway.
 
They are the GP carrying large numbers of mental health patients who have slipped through the cracks of every other service.
 
Having long ago given up on finding a local psychiatrist with open books, the GP is doing their best with remote telehealth. They sigh as the psychiatrist’s letter requests another long panel of blood tests and regular ECGs.
 
They are the GP who selflessly continues to care for their patients in nursing homes, in spite of poor remuneration and the stress of multiple phone calls out of hours. They are doing their best to manage confusion, falls and weight loss in a system with no support and no time.
 
They are the GP who has been trying for weeks to get their patient accepted by the public hospital outpatient clinic. After three rejected referrals, they are told that, in spite of their patient’s PR bleeding and concerning change of bowel habit, they will not be seen until the GP adds iron studies to the hospital referral form.
 
Nudge letters are not harmless.
 
They inflict enormous anxiety and dread amongst GPs and inject a real sense of fear into clinical decision making. Many GPs are already feeling burnt out and are contemplating how to transition out of the profession.
 
Trainee numbers are at a frighteningly low rate.
 
Targeting GPs in this way is inappropriate and discriminatory against those who practice high rates of women’s health, mental health and aged care.
 
How much taxpayer money goes into the distribution of these letters?
 
It seems contradictory to be telling GPs to stop spending money ordering blood tests whilst funding is being used in this way.
 
If the desire is to cut back on unnecessary tests, why not simply fund some education for GPs through gplearning or NPS modules? Why not ensure that Health Pathways are updated to include this recommendation?
 
This would have been a respectful and safe way to communicate with us, that would not have caused the distress and outrage currently burning through the profession.
 
We know there is wastage in the healthcare system. We know that good stewardship of Medicare is a part of our professional responsibility. However, given that general practice receives such a small share of healthcare spending, this cannot be the most effective means to target spending.
 
Many GPs who have been sent letters this week are working in rural and low-income areas. They are holding together the aged care system with their bare hands whilst resources and funding disappear.
 
They are doing the heavy lifting in a broken mental health system.
 
They are doing hard medicine with challenging patients. They are filling gaps, picking up pieces and taking on jobs nobody else wants to do.
 
These GPs don’t deserve threatening letters. They deserve a standing ovation and a significant pay rise.
 
These doctors are not the enemy of the healthcare system – they are keeping it together.
 
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Dr Jen Low   24/05/2022 7:25:42 PM

I am the above and have been nudged this week. I see brittle Eating Disorder patients, I carry the bulk of mental health consultations for my practice, I support our antenatal patients and see my fair share of the fatigued, TATT middle-aged, peri-menopausal women. This weeks standard letter., with cherry picked data, made me question how I practice….has it been wrong over the last 23 years?…..I will do the recommended CPD task, Ive logged into the RCP reading, which funnily enough doesnt include any of the above diagnoses in its recommendation of path testing, and Ill jump through hoops. This “nudge” may be the shove many burnt out GPs are waiting for to leave practice at a time when we really need support, reassurance and solidarity.


Dr Avi Charlton   24/05/2022 9:05:26 PM

So true with the above article. I have been 'nudged'. I am a female GP working seeing majority women, pregnant, young girls, who are tired, fatigued, not eating well, low iron, often metabolic syndrome, obesity, poor gut health. I want to practice preventative health and pick up conditions and give them lifestyle advice , especially diet, nutrition so they can improve their health and eventually save money for the health system.
There is also a GP shortage. With this 'nudge' letter, I am now having anxiety every time I order pathology. In an almost burnt out GP, it is not good for our mental health. I do not think this 'nudge' has achieved anything but is a bully to a subset of GPs who are female, keen to look after patients , and want to improve patients lifestyle!


Dr Kannan Ramanathan   25/05/2022 4:53:07 AM

I have a slightly different take on this. The doctors or the pathologists who write these letters, think that they are smart, intelligent and have achieved the zenith of the pathology or any field that they are in.
Please do remember, the GPs see the patients and lots of factos play into ordering tests. I agree rational testing needed to be done.when you doubt certain disease, for example, eating disorder, celiac, when you add iron studies along with celiac studies , when patient claims anemia.
How great are the so called clinicians when they vouched for digital rectal exam for identifying prostate cancer , and now, say it is not that reliable. I can quote many examples.
please look at history. you can google it or go to library which holds journals as old as 1890s. so called eminent doctors at that time thought disseases were due to bad blood. what did they do? They 'prescribed' leech bites three times a day!! They are now riduculed. So will we all be in 100 years


Dr Alexandra Bernhardi   25/05/2022 6:49:15 AM

I have looked after a rural nursing home with 50 Percent Indigenous residents, almost all residents were suffering from dementia or brain trauma. Of course I tested for iron, Vit D and TFT. Not surprisingly I received a lot of pathological results which I was able to address and treat. I believe I did the right thing given the high prevalence of above deficiencies in this group. I have received one of these APHRA letters - which saddens me immensely.
It does not reflect poorly on me but on APHRA.


Dr Bernd Lorenzen   25/05/2022 6:51:55 AM

If another doctor, say in my practice, screwed up a pathology request I had prepared, declaring that test unnecessary and wasteful, and the consequence was a missed cancer, then that doctor would hold vicarious or sole liability. Not so faceless mandarins who can throw a grenade, walk away, and the damage they leave behind is yesterday’s news to them. Apparently these letters change behaviour, but when the outcome metrics are fiscal and not health outcomes, it is perverted intent.


Dr MT   25/05/2022 7:28:36 AM

I hope the RACGP president will stand for us and speak to the people who set out these ridiculous rules to threaten GPs mental health . The rule 80/20 including Telehealth also put an enormous pressure on us. The Government has been dealing with shortage of health care professionals . They have tried many different ways to find health care workers, including ‘ importing from overseas’. Every single message on media about illness, disease, heath matter etc. always mentions: ‘ contact your GP, talk to your GP, see your GP’. During the Covid pandemic and now the flu season, we see messages like’ Don’t go to ED, ED in crisis, go to your GP’ … GPs also have a duty of care to our patients. It is difficult to refuse to talk to or to see patients just because ‘I have enough number of patients that Medicare allows me to see ‘. GPs are ‘family doctors’. I have seen quite a few family with 4 generations and I am the only GP in the area. IT IS REALLY STRESSFUL TO FOLLOW THE RULE OF 80/20.


Dr Jane Morgan   25/05/2022 8:15:50 AM

Firstly I'd like to thank Dr Deborah for her excellent article .I'd also like to state the sense of relief it gave me to read and that it helped rationalise my response to my duly received "nudge" letter.

In our profession,one of the hardest parts is dealing with uncertainty.None of us want to be the one who "misses" a particular diagnosis.Yet we juggle this with the knowledge of the potential harm done by overordering tests, costs to medicare etc.

Once again ,instead of an iota of support offered us by the government. , we are dealt a judgement that is not only largely irrelevant,costly but is also statistically skewed! However, it still causes anxiety,frustration and anger.

And accentuates the strong feeling of wanting a different job!!


Dr Mahavir Prasad Gupta   25/05/2022 8:24:37 AM

I keep the letter in my briefcase and show this to the patient whenever someone specifically asks me for ordering these tests, unless convinced about absolute necessity- with the apprehension of missing abnormality in some patients. Same thing I started doing when someone asked me for the Xray/imaging- unless convinced about absolute necessity- with the apprehension of missing abnormality in some patients. I had to face the anger of some patients and abuse and preferring to see other doctor, but I believe it is better than being targeted by authorities with the possibility of being penalized later or medicare threatening to recover money or charging penalty!


Dr Oliver Ralph Frank   25/05/2022 8:58:57 AM

I have seen these combinations of investigations, often with CBP/FBE, biochemistry, lipids and sometimes also C reactive protein, being requested for patients who are well, as part of something referred to in the patients' records as "annual bloods". This is not recommended by any guidelines that I know of.

There is a big difference between doing this and thoughtfully and selectively requesting relevant investigations for patients who are not well.


Dr Penelope Batterham   25/05/2022 9:21:53 AM

I have also been ‘nudged’ and subsequently questioned the way I practice but I am comfortable with my decisions. I also see the tired women, with multiple complex conditions, ranging from young teens to the elderly who are almost always iron deficient and vitamin D deficient when I check. B12 and TSH are part of the reversible causes of memory loss screen that I do for many of my elderly patients- and part of a fatigue screen- again more often than not resulting in deficiencies being picked up. I wonder if the assessment of my testing rates also included an assessment of the percentage positive results!! It’s interesting that the pathology tests of concern and subsequent treatment benefits tend to benefit women and the elderly.


Dr Juanita Susan Ruiz   25/05/2022 9:32:44 AM

Dr Jen … keep up your good work !


Dr Naseem J. Chowdhury   25/05/2022 10:28:17 AM

Yes I have been nudged. Fair to say that fiscal guidance is a necessity. But is not more appropriate that the doctors patient demographics be checked before sending out these computer generated mindless letters. I have been a GP for more than 30 years and with a great record so far, training medical students and GPs, still seeing nursing home patients, predominant female and mental health practice, so it does not feel good when confronted with such letters. Who ever you are please do your homework before insulting us.


Dr Timothy Ray Lipscombe   25/05/2022 10:51:28 AM

This is a beautifully written piece. I am extraordinarily frustrated that health bureaucrats and politicians do not understand the link between the failing health system and the fact that General Practice has been allowed to wither. The great Professor Barbara Starfield showed in her research decades ago the connection between good health outcomes for populations and a robustly healthy primary care system .


Dr Abdul Ahad Khan   25/05/2022 11:57:13 AM

" Nudge letters are not harmless. "
" They inflict enormous anxiety and dread amongst GPs and inject a real sense of fear into clinical decision making. Many GPs are already feeling burnt out and are contemplating how to transition out of the profession."
" Trainee numbers are at a frighteningly low rate. "

Deborah, your above Statements are Succinct & Accurate.

DR. AHAD KHAN


Dr Stephen Jarvis   25/05/2022 12:23:35 PM

In 1983 bulk billing started and the AMA warned that this meant the start of rationing for access to General Practice in Australia. Every one wanted " free medical care". In 1985 my associate and I were in a practice in a low socioeconomic
area. We were told by the medicare advisor that 2.1 house calls per day was too many. We had single mothers, pensioners and health care card holders who we as two keen young practitioners thought needed access to home visits. Of course we were cheap compared to an ambulance, ramping and ED care but this implication did not worry the bean counters. Next came the reduction in working hours for practitioners based on patient numbers regardless of practice demography , practitioner experience or practice care efficiency. Sadly I see the present pathology review a continuation of this rationing which is to further reduce access to primary care medicine and costs. In our last election more pie in the sky super clinics are promised.


Dr Robert Charles P Hills   25/05/2022 4:09:52 PM

Thank you for an excellent article, Dr Carrington.

It's curious that as a (male) GP working in a bariatric clinic and ordering nutritional screens VERY regularly, I've not (yet) received a nudge letter. Maybe I don't work enough days a week to appear on their radar? Maybe there's a gender bias in the letter targeting?

I believe there is a way this could be done that could be useful and alter behaviour, but in a collaborative way. Unfortunately it would likely require more effort than our Health Mandarins have available to spare!

I would welcome collaboration between the health department and pathology providers to feed back to me statistics on:
- specific investigations I order vs my peers; and, more importantly
- my positive result rate for each of these investigations, compared with my peers.

I would welcome a 6-monthly or annual letter with those statistics to help me determine if I am indeed being as effective and efficient with my investigations as I hope I am!


Dr Fiona Jane Henneuse-Blunt   25/05/2022 5:33:47 PM

I wonder if our rheumatology colleagues receive similar letters?
My main bugbear are the requests from patients for lists of unecessary investigations as suggested by their Naturopath. (Who can apparently charge more than I do for a consultation). I refuse anything that is in my opinion a ridiculous request and remind the patient that I become responsible for the cost to Medicare and the interpretation of the results.


Dr Olubunmi Temitope Mabo   25/05/2022 6:34:21 PM

Thank you for a great article, Dr Carrington. Succinctly expressed views . You speak for many of us.


Dr Merrilyn April Gates   25/05/2022 8:09:54 PM

Thank God for this article. Me too. ME TOO. Oh yeah, and I do lots of geriatrics, lots of menorrahgia (Mirena insertions, the only one in a big clinic to do them), eating disorders, nursing home patients and Clozapine. Sounds like a breeze....NOT. Not only that, But I showed up in person every day since this pandemic started, seeing other people's patients when they hid behind their phones, and I contend, probably ordering pathology on their behalf. Thanks, Canberra, for scaring the bejeezus out of me, causing me a sleepless night or two and lots of anxiety. I really needed more of that. Now I'm waiting for the PSR to come knocking for all my item 36s. Counting down to retirement, Canberra penpushers, counting down.


Dr Annette Rose Skarschewski   25/05/2022 8:21:31 PM

I got one, but I do a lot of opportunistic preventative health and geriatric health and I feel I can justify what I do. I pick up so many pathologies with these tests that I am reluctant to change my practice. Only last week I had a 47 year old man come in for a knee issue and I ordered these blood tests and found that, despite a normal fbe, he had a very low ferritin. This lead to me diagnosing him with coeliac disease. He was asymptomatic. Patients like this may only see a doctor every few years so I take the opportunity to screen them when I can. I believe I am saving money by finding pathology before it is severe and/or irreversible. This initiative seems to me to be very much penny wise, pound foolish.


Dr Jacqueline Chapman   25/05/2022 8:41:17 PM

It seems many doctors face the same frustrations I do -Requests by patients, suggested by untrained ‘experts’, for unnecessary tests which take time and effort to persuade them are not necessary and the absolute amazement at the number of tests specialists organise without any good reason, including imagining that I have purposely not organised as we are held to account if we do. How do we respond to these regulatory bodies, PRU included, who bear no responsibility for patient care and adverse outcomes, but still insist they know best how we should practice? Assessment of case mix and understanding the variability of a GPs work is obviously beyond them. I believe those who have received such a letter and feel understandably traumatised, should seek redress through their insurer and the college. After all bureaucrats also need to be accountable and to prove that they know what they are doing. The evidence in support of this is so far sadly lacking.


Dr San   25/05/2022 9:32:30 PM

When a patient requests a pathology test or investigation that in my opinion is not clinically indicated, such as their blood group in some cases, or a full hormone profile instead of just FSH, I explain to them that I am willing to request the tests they or their naturopath would like, but that it won't be covered under Medicare unless it's clinically indicated. Most patients accept this, if they've gone down the path of paying for a naturopath. I let them know I'm happy to liaise with their alternative health practitioners unless I think a certain treatment would be harmful to them- like the Cansema black salve. I want them to feel they can be honest with me about medications they are taking and therapy they receive. I do sometimes advise "I'm not sure if that will help, but I don't think it will hurt you, except maybe your wallet."


Dr Alina Tatiana Yaremenko   25/05/2022 9:34:35 PM

Thankyou for the article. When I received one of these letters I wondered if it was time to leave general practice. I am so grateful for your article. I see the most complex of patients, often referred to me by specialists or psychologists, have continued face to face consults throughout, managed many patients who should have been being managed by specialists or in hospital but unable
To access that level of care, picked up so many abnormal results through the testing I have done, and often bulk Billed to help people strained by the pandemic. I have bought all my own PPE, largely had to implement strategies before they were realized by authorities to be necessary. I have worked 6 days per week to do regular clinics and vaccination clinics.. It was beyond disgusting to receive that letter! Shame on anyone who had anything to do with it!


Dr Leanne Joy Barron   25/05/2022 10:49:34 PM

Thank-you Deborah. Your letter has summarised beautifully the points I too wished to raise in reply to this letter.
The targeted bloods indeed encompass this vulnerable set of patients - being exactly the tests indicated in many cases of mental illness. It does seem strange when governments are pledging ever increasing spending on mental health services that they should deny such basic general practice screening. The costs of the bloods are low when one considers the potential for many years of personal and family suffering /lost income (and psychological support/ disability services/pensions required ) for the undiagnosed patient with B12 deficiency, with hypothyroidism, with anaemia, with coeliac disease, with vitamin D deficiency....
Is it really fair to practise "watchful waiting" in these vulnerable populations?


Dr Laurence Vogler   26/05/2022 12:25:21 AM

I received one of these. I had a feeling I might get one. I looked at it long enough to turn on the shredder and briefly wondered how much carbon units this farce wasted.

Then I did what any self respecting GP would do..., I called in my next patient and did exactly what I needed to do to diagnose and manage them. Nothing more, but certainly nothing less.


Dr William Trevor Hurlow   26/05/2022 9:16:55 AM

This latest nudge (some have received) is a sad addition to the way attempts are made to control and pressure us as professionals. Stress we don't need!
- are we perfect - no!
- have we all ordered unnecessary tests due to patient/ allied health/specialist pressure and also from our own uncertainties and possible past mistakes - yes!
We stand by you!

A personal story: My best friend - age 58yrs went to his GP for his annual check/ bloods - feeling super fit and no complaints. GP - reported back - everything normal - my friend sent me copies for my comment. Only change was a drop in his ferritin/iron stores (still within normal limits!) no Hx of PR bleeding, Fhx neg for colorectal cancer.
FOB advised GP obliged - came back as neg.
I advised him to request a gastroscopy/colonoscopy (Gold standard test for colon pathology) - this was done and he had colo-rectal carcinoma - further chemo and resection. He is alive and well 12 yrs later.

We all have similar stories!


Dr Thet Oo Han   30/05/2022 12:20:42 AM

If they want to reduce the unnecessary tests, it is very simple. Just cut the rebates for the pathologies so that they need to charge the patient. Then the patients will start to think twice before asking for those unnecessary tests. Today, I saw a child whose mother kept pressing me to order blood tests due to a week of fatigue. When I said no, she even threatened me that they will see another GP to do the job. Well done with this universal world class bulkbilling system.


Dr Christine Human   30/05/2022 9:16:19 AM

So true, dr Carrington and other respondents. Part of my practice is in a very affluent area. The amount of iron deficiency that I pick up, often from female patients who goes vegan without proper education flummoxed me. And of course, I can also relate to my other low socioeconomic practice, for all the reasons stated by this thoughtful letter of Dr Cartington. Karen Price, it is time that you stand up for all of us who voted for you.
As for the nudge letter, I am so burnt out that I could not care less. I haven’t even opened it.


Dr Greg Saville   2/06/2022 4:59:26 PM

This is a dreadful article filled with misinformation and completely misunderstanding the concept of the nudge letter. They are not “please explain” letters - these should fill you with dread. A nudge letter should fill you with excitement and hope.
I suggest the author and all the commentators read the following books: Nudge, Inside the Nudge Unit and Think Small. All excellent.