Presentation on theme: "Pressure / No Pressure Strategies for Pushy Patients Dr David Bratt"— Presentation transcript:
1Pressure / No Pressure Strategies for Pushy Patients Dr David Bratt Anne HawkerHealth and Disability Advisors to MSD
2Menu Sources of Pressure for the GP and for General Practice? Work and Income “Work Capacity Medical Certificate” as an exampleEvidence based practiceUnderstanding the patient in their contextStrategiesDiscussion/questions
4Pressure Keeping patients waiting Time Patient demands After-hours Cover/Locums/SuccessionFinanceStaff
5Patient One32 yr old male arrives with 82 pages of print-out off the Internet – asking that you quickly read this conclusive evidence and then order the indicated tests for his persistent fatigue – hair sample for dioxin (must go to the USA), special thyroid tests (from Melbourne lab) – and that you arrange for his mercury fillings to be removed and prescribe anti-fungals and mega doses of supplements and vitamins.
6Patient Two17 yr old schoolboy 1st XV rugby player here with is father after twisting his ankle in the weekend game. There is a key inter-school game next week – and father is demanding an Xray.The lad is walking reasonably well – slight swelling and tenderness over the antero-lateral aspect of ankle. No bruising and no instability.
7Patient Three26yr old NZ male with 2yr history of lower back pain who reports just returning from Australiaproduces letter on Royal Brisbane Infirmary letterhead saying he has been treated with Sustained Release Morphine Capsules 100mg bd – and he needs some moreyou briefly examine him – sits comfortably, nothing remarkable except lots of tattoos, but has a reluctance to flex his back on request
8Patient Four26 yr old NZ male recently returned from Australia – tells you a Work and Income case manager had told him he was eligible for an Invalid Benefit because he has had back pain for over two years which had prevented him working. He was working as a builder’s labourer – a casual working for cash.AND – he just needed to see a GP who would fill out the necessary medical certificate.
9Survey of GP’s Re Work and Income 72% of GPs deal with 5 or less W & I Medical Certificates a week (30% 0 – 2; 42% 3 – 5)Which form of Med Cert?44% use the MedTech Advanced Forms ;32% the paper version;still 24% using an outbox versionDiagnosis &/or READ code65% put both
10GP Survey cont. Sources of pressure felt by GPs 71% felt this was the mechanism to provide income to the patient55% - felt W&I staff created an expectation40% - because they believed there was no work available31% - felt W&I werent doing anything for the patient30% - had experienced a sense of threat and intimidation
11GP survey cont Contact with W&I 62% had been contacted by W&I On a scale of 1 (waste of time) to 5 (v. useful) the average was 3.72 (75% satisfaction)61% had requested to be contacted with slightly less than half having received a call back.
12Urban Myths“If you don’t sign this form Doc I wont have any money – and will lose my flat.” True? or False?Unemployment Benefit is > ; = ; < than a Sickness Benefit?An Invalid Benefit is > ; = ; < than a Sickness Benefit?
13The Financial Reality Benefit rates Net per week Gross per year UB & SB < 25yr $158.65UB & SB > 25yr $190.39UB & SB couple $317.30IB – single $237.97IB – couple $396.62DPB $272.70Gross per year$9,428$11,315$18,856$14,158$23,571$16,44413
14The numbers are people too! 20 Aug 2010UB ,066DPB - 113,166SB ,867IB ,545Other ,078Total - 347,72231 July 2008UB ,712DPB ,099SB ,964IB ,745Other ,304Total ,824
15Adverse Effects“Long term worklessness is one of the greatest risks to health in our society. It is more dangerous than the most dangerous jobs in the construction industry, or working on an oil rig in the North Sea, and too often we not only fail to protect our patients from long term worklessness, we sometimes actually push them into it.”Prof Gordon Waddell 2007
16What Adverse Effects? Increased risk of dying Increased risk of dying from Heart disease, lung cancer and suicidePoorer physical health, including heart disease, high blood pressure and chest infectionsPoorer general health and poorer self-reports of health and well-beingIncreased long term illness
17Psycho-social Impacts DepressionErosion of work skillsDecreased income and social statusLoss of social support networksDecreased confidence and Decreased sense of self-efficacyFrom “Journal of Occupational Rehabilitation”, Vol. 4, No 2, 1994
18But Wait – There’s More!Research into the impact of parental unemployment on children has found:higher incidence of chronic illnesses, psychosomatic symptoms and lower wellbeingmore likely in the future to be out of work themselves, either for periods of time or over their entire lifepsychological distress in children whose parents face increased economic pressure – anxiety, depression, delinquent behaviour, substance abuse
19“Worklessness” If the person is off work for: 20 days the chance of ever getting back to work is 70%45 days the chance of ever getting back to work is 50%70 days the chance of ever getting back to work is 35%
20The FactsNZ has the worst child health statistics in the 29 OECD countries – A NATIONAL SHAME1 in 5 NZ children live in a household with no-one in paid workHealth outcomes for someone out of work for 12 mths is awful – equivalent to smoking 10 packets of cigarettes a day!3 in 10 employees will experience mental health issues at some point in any year
21Determinants of health educationemploymentincomehousingaccess to medical and related services21
22ICF Health Condition (Disorder/Disease) Body Function Activity Participation& Structure Environmental Factors Personal Factors22
23Consideration“It’s much more important to know what sort of person has the disease than what sort of disease the person has”Sir William Ostler, 189623
24Non-Medical Factors in Work Absence perception that a diagnosis alone (without demonstrable functional impairment) justifies work absencefear of pain or re-injuryconflicting advice and/or inadequate communicationconflict in the workplaceunhappiness with aspects of working environment unsupported, lack of acknowledgementfamily beliefs and actions
25GP Barriers to managing health and work issues the doctor-patient relationshippatient advocacypressure on consultation timelack of occupational health expertise (or a perception of such)lack of knowledge of the workplace
26So What to Doencourage your patient to expect that they will recover and return to suitable workactively monitor your patients progressprovide information about the role of work in rehabilitation and the importance of remaining activeidentify medical and non-medical barriers to return to workpromote an “active management” approach to recovery, and work in tandem with other health professionals
27A Daily Reality!the “benefit” – an addictive debilitating drug with significant adverse effects to both the patient and their family (whānau) – not dissimilar to smokingand NZ GPs write 350,000 scripts for it every year!
28Questions and Suggestions Any questions?Any suggestions?And Thank You!