Top-of-scope rhetoric is a competition between clinical tribes for funding and prestige at the expense of a patient-outcomes focus.
There’s a lot a rhetoric around clinicians working at the top of their scope of practice.
As a staff specialist working as a clinical director of a public hospital drug and alcohol service, I believe that my team already does that and has done for years. I am salaried and, at least for the moment, our service is block funded since we operate in an area of market failure.
But I had pause to reflect on how that might look and feel for patients and my colleagues in a primary care general practice setting.
I recently had the good fortune of attending the “Towards One Healthcare System Summit”, hosted by Allergy & Respiratory Republic’s sister publication Health Services Daily, in Canberra. All the usual stakeholders were there, including officials from state and commonwealth health departments, AI connectivity tool vendors, and consumer representatives.
The vast majority of doctors present were specialist GPs.
We have one of the best health systems in the world, but it could be better. Our systems are fragmented, with many integration issues.
Normally we speak of integration in health as a horizontal or a vertical phenomenon. But our systems appear to be more of a checkerboard, as described by summit presenter Associate Professor Alam Yoosuff, a GP and board director at the Murrumbidgee LHD.
Due to the constitution, we can never have one healthcare system. We have eight major players in the ecosystem covering funding and legislation. It could be argued that these players perversely foster competition, rather than collaboration.
In a public hospital system, all the clinical tribes are under the same roof and have common governance. This contrasts with the primary healthcare system, which is largely comprised of solo practitioners, many with special interests, who are geographically separated. Block-funded NGOs are one exception to the norm.
At first glance, there’s a positive value proposition that all clinicians are working at the top of their scope of practice. The public healthcare spend that supports GPs via the Medicare rebate must be defendable. But let’s take a deeper dive.
I have two conundrums.
I agree with Professor Yoosuff – scope of practice is neither horizontal nor vertical. It has a checkerboard-like division. Allow me to elaborate.
When I did my undergraduate medical degree in the 1970s, we were told that the “practice” of medicine was a dynamic sweet spot somewhere in the middle of a conceptual triangle, with the science of medicine, the art of medicine, and the craft of medicine forming the three vertexes.
My first conundrum: When we speak of scope of practice, which vertex are we referring to? Are we targeting the medical, the arts, or the craft expert? Craft can be divided into hard and soft skills. Which of the three vertexes makes the patient journey more patient-focused, safe, and satisfying?
Medical science has for the past 40 years been hijacked by the evidence-based (EB) acolytes. In my view EB is a dynamic entity, and an EB industry has arisen that has become self-serving. We need evidence, but it was David Sackett who argued that we should not allow evidence-based methods to be used as a tyranny.
In the main, EB in medicine is quantitative. The patient experience is qualitative. I’m going out on a limb here, but I believe, as a rule, doctors loathe qualitative evidence. This blind spot has traditionally been built into the curriculum of university medical schools and medical specialty colleges.
Stated bluntly, the common view seems to be that qualitative evidence is for social workers and not doctors.
We have forgotten William Osler’s dictum: “The good physician treats the disease; the great physician treats the patient who has the disease.”
To do this requires the clinician building a therapeutic alliance with the patient. These are soft skills, craft and art competencies. In practise, it’s spending time developing a safe space for the person to reveal themselves. This will lay the groundwork for quality history-taking and will provide a better opportunity for making a more accurate diagnosis.
Once a provisional diagnosis has been made the job has just begun. This is especially the case in chronic disease. To my mind, the real complementary medicine component is prescribing appropriate pharmacotherapy. The real medicine is the accompanying psycho-education, the coaching and conversational therapies that will help begin the necessary lifestyle changes. It is these components, used with active and reflective listening, that will make the patient journey more satisfactory and improve compliance and therefore clinical outcome.
Do patients want this journey to be handballed between various clinicians? Which part of this medical process can a GP outsource, because it’s not top of scope.
In my own practices, do I sit the patient in front of a computer and get them to provide answers to an AI-generated algorithm? Do I outsource the psycho-education to a YouTube TED talk? Having invested time developing trust in a therapeutic alliance, do I then handball the patient to a practice nurse to do the ongoing monitoring?
As an aside, in defence of AI recording, I would certainly appreciate the support of a scribe, as I am a two-finger typist, and I don’t record my notes in real time as I believe it puts a barrier between the patient and me. Is this top-of-scope argument a call for efficiency or is it a Trojan horse for competitive stakeholders to increase their reach?
My second conundrum arises out of the need for task variation.
Allostatic load is generally measured through a composite index of indicators of cumulative body stress and strain. If I line up the tasks that comprise my scope of practice in order of their allostatic load, and then discard those which are low, then conceptually I’m constantly running on full throttle.
This means I have no downtime, no time to regroup, no time for enjoyment.
There is already a serious burnout issue in the medical industry. Will constantly working at the top of our scope exacerbate this. Does it kill discretionary effort and decrease productivity?
I think change is inescapable and I welcome it. Task re-engineering must certainly be on the table. But it must be well-considered. As always, the devil is in the detail.
At this point, I see top-of-scope rhetoric as a competition between clinical tribes for funding and prestige at the expense of a patient-outcomes focus. Of course, this doesn’t help GPs who operate in the complex primary healthcare space, when in Australia, hospital funding has been increasing over the past 10 years, and primary healthcare funding has been decreasing over the same period.
Let’s keep talking.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
