GPs help candidates by becoming campaign managers, “selling patients”. Horrible term, common requirement.
It’s not easy getting healthcare these days. When I started, GPs just didn’t reject patients. The older doctors explained that everyone has a few challenging patients, and when one died or moved on, another would inevitably arrive.
It was our lot.
Now, of course, there are clinics who pick and choose. Some clinics audition their patients and reject the ones who don’t fit their model of care, or (let’s be honest) their preferred bottom line.
So, the process of getting patients into services is becoming more complex, and more critical.
“Candidacy theory” describes the way people need to earn their way into services. Here’s how it works.
The pitch
If you want to access a health service, it usually means finding out the intake criteria and meeting the requirements. Thank goodness for search engines and (for the younger population) Tik Tok, because algorithms for candidate selection are usually available online and allow the candidate to rehearse their approach.
There are never enough services, beds or health professionals and there is always a competition for precious services. As GPs, we know this in our bones.
Sometimes, becoming a candidate for a service means demonstrating that you have the literacy, numeracy, time and contacts to navigate the complex bureaucracy. Often, we GPs will be involved in lending our own skills to overcome these barriers. Consciously or not, the barriers reduce demand for high bureaucracy services like the Disability Support Pension, NDIS and My Aged Care.
It’s not fair, but it does the job of reducing costs.
People have to audition for scarce services, earning their way in. When services are very restricted, like hospital beds, the outcomes of this process can be brutal. It is rarely equitable, with inherent advantage going to the privileged, who can work out the rules or even have insider knowledge and influence.
Auditioning can include dressing the part (not too dishevelled because you may be too high acuity for the service, not too refined or you may not be sick enough), behaving like a credible patient, ensuring you tick the right boxes on the intake form and even using magic words (and avoiding words that trigger dismissal).
Unfortunately, the data suggests that some people have to work harder than others to earn their way, and it is still profoundly difficult for those who live with multiple marginalisations.
If there is a questionnaire involved there may be cutoff scores. In mental health, this is particularly problematic.
We all know that the stoic will undersell and the histrionic will oversell, so let’s not delude ourselves that outcome scores on a DASS or K10 have some objective reality. If the patient needs the service, you need to meet the score.
GPs help candidates by becoming campaign managers, “selling patients”. Horrible term, common requirement.
We do this with referral letters, emphasising the virtues of the patients: “Mrs Smith is a lovely/delightful/capable woman” – and NOT using anything that will impact the perceptions of their worthiness – no “complex” or “challenging” and certainly not “difficult” patients please!
It is always good to imply that the patients need the service’s help, by buttering up the clinicians a little. I will use the phrase “I would be grateful for your expertise in managing Mrs Smith who has a perplexing constellation of symptoms”.
I am not above implying that I don’t know what to do, because some health professionals respond to the validation – “I would appreciate adding occupational therapy to the multidisciplinary team, because she and I think she would benefit greatly from your disciplinary approach”. It’s true, but it is also affirming.
Evoking sympathy is a good thing, as long as you don’t do it too much. Do it too much, and it loses its power, because you will be known for it, and the service will cease to empathise with your patients.
Doctors trying to get needy patients from developing countries into Western services have known this for decades. For every child with a disfiguring facial tumour getting expert surgery, there are many more who don’t.
This is why the NDIS stopped GPs being so involved in care. We tried to get services for too many people, appealing to the compassion of the service. There is only so much of that sort of thing a bureaucracy will bear.
Related
The case
Let’s look at an example of how the situation really works.
Mx Taylor has non-specific but severe and escalating abdominal pain. They are a young person, born female and gender diverse. Taylor has been here before and the cause of the pain is unclear:
- Taylor has to convince the ED team that they deserve to be seen. This involves demonstrating that the pain is severe, but not triggering the concerns that they are either “being dramatic” or drug-seeking. It is even harder if Taylor is not fluent in English.
- The need to prove worth is stepped up a notch if the x-ray/blood test/CT scan is normal. There is a cognitive bias towards believing “objective” evidence over “subjective” evidence, especially if the clinical signs are unclear. Let’s assume the ED team is concerned enough to be unhappy to send Taylor home. The next step is subjecting them to a vote.
The vote
Many of us have read The House of God, a deeply cynical, but quite accurate, portrayal of hospital life in the 1990s. Samuel Shem introduced the world to the medical slang of the time, and the nasty underbelly of medical practice in hospitals.
One of these ideas was the concept of “buffing and turfing” – making a patient look good enough to be acceptable to another team.
Taylor has four choices for candidacy:
- The surgical team. This is an unlikely option, as there is clearly nothing on a CT to remove, replace, repair or drain.
- The medical team. In the presence of normal blood tests, and the absence of chronic disease, it is likely that Taylor will be “turfed” because “we have nothing to offer”. I don’t know when hospital beds were allocated according to how much the hospital can help, rather than how severe the illness is, but it is an unfortunate reality that you can have a worthy candidate these days with no role available, and they will be exited from the system. GPs can assist here by suggesting potential rare or significant disease. I once got a patient with severe antenatal psychotic depression into hospital when she’d been rejected by psychiatry (pregnant) and obstetrics (not pregnant enough) by telling the infectious diseases registrar that she was delirious with an unvaccinated herd of cows and potential leptospirosis. It was sort of true, and it got her in the door.
- The gynaecologists. Usually, you need a background history of something gynaecological, but sometimes the suggestion of severe endometriosis will get you in the door.
- The superspecialists. In the absence of anything else, this is usually impossible, but sometimes there is a blood test that signals a possible infectious/autoimmune/rheumatological condition just itching to be made. It rarely gets the patient admitted, but it might earn an outpatient appointment.
- The psychiatrists. The poor psychiatrists are often landed with patients who don’t have enough physical illness to earn their place anywhere else. Unfortunately, they rarely have a psychiatric illness, and there are never any beds anyway.
The result
Taylor is likely to be exited from the system, back to the GP who is not equipped to deal with the severity of the illness, not able to prevent an increasingly likely poor outcome but still medicolegally responsible.
The Medical Board and/or coroner will rarely accept an excuse like “I tried to get care and it wasn’t available”. So, like an abscess, we need to get the patient in the door at the exact point where their contents of the illness can be seen and fixed. It’s not easy.
Governments have invested heavily in services that meet the needs of candidates for straightforward problems.
Let’s not delude ourselves that Taylor will get any help from Medicare Urgent Care Clinics, Medicare Mental Health services, specialised primary care services, pharmacy or hospital in the home. All of them are more heavily funded than me.
What they need is an intelligent series of hospital teams and a precious hospital bed but what they get is the GP holding the risks of an unstable patient they cannot adequately treat.
Being an unsuccessful candidate, or a campaign manager of an unsuccessful candidate is deeply challenging, inhumane and dehumanising role. It shouldn’t be necessary. Tik Tok and other forms of consumer empowerment means candidates are becoming more expert, and so the competition is fiercer.
Taylor deserves better.
Professor Louise Stone is a GP in Canberra and an academic at Adelaide University. A collection of her research, policy and teaching materials can be found at drlouisestone.com.
