Is it ethical, correct and legal for a family doctor to treat 60 patients in one day?

Salvador Casado

My point of view: No, with exceptions.

Medicine is a highly regulated activity. Its exercise requires a high level of education and academic level, a high code of ethics and deontology and appropriate legislation. In other words, it cannot be exercised in any way because of the potential risk of damage for patients. 

Surprisingly, care overload is not defined, regulated or correctly managed. 

Why? Simply because it is in the interest of private health organisations to take on high volumes of consultations in order to increase their profits and public ones in order to reduce an ever-growing waiting list.

In this way the chronic under-funding of the public system added to the progressive increase in the health needs of the population make the whole system inevitably tend to overheating, being constantly overload.

Is anything being done to prevent this drift? Not enough, given that recalculating the financing and improving the management structure are not politically profitable, as they oblige in all scenarios to increase public spending and/or assume restrictive measures that are never popular. Unpopular changes that offer benefits in the medium term, much greater than the four-year horizon that every politician assumes. 

What exceptions are there for a family doctor to see 60 patients in one day?

1. Punctual overload (absence of 50% of the staff simultaneously, epidemics, catastrophes).
2. That the vast majority of these consultations are administrative.
3. That the professional is a gifted with superpowers.

If the overloads are frequent and continuous (more than 20 working days a year, let's put it as a limit) we do not consider it an exception but a maintained overload. If there is a large number of administrative queries (hospital-level prescriptions, reports, paper prescriptions for failure of the electronic prescription module, sick leave reports...) it cannot be assumed due to negligence on the part of those responsible for management. 

To assume that a professional is gifted with superpowers is irresponsible and a mockery. Professionalism’s abuse is unethical since the price of this overload favours the burn out syndrome with negative consequences for both professionals and patients.

Apart from the exceptions, a situation of maintained medical overload is not ethical, correct or legal, why?

1. Patient safety. It is impossible to provide a sufficient level of quality in complex situations of overload with very limited time. Complex patients need longer care times to avoid safety problems.
2. Professional exhaustion. Health professions are characterized by the high degree of attention required for their correct exercise. Long working hours (guards, concatenation of shifts...) and/or intense (more than 30 patients per shift), put the professional at risk. 
3. Iatrogeny. It has been shown that errors increase with the overload and fatigue of the professional. Imagine that we force an airplane pilot to do several consecutive shifts or a firefighter to put out two fires at the same time. Keeping a doctor on duty 24 hours a day or forcing him to see patients who are usually seen by two doctors increases the risk of error. 
4. Bad social education. Assuming that the citizen can consult the health services for any minor discomfort or issue arising from normal life saturates any health system no matter how sophisticated it is. It is essential to develop regulations that help citizens to improve their self-care and assume that life entails discomfort not susceptible to health action. 

What can be done to correct this situation?

1. Definition of overload lines. It is essential to use consensus qualitative indicators. We could start working with the number of persons atended, corrected by social, community and age variables. And create new indicators such as days of the year that overcome a certain pressure and others that can be designed. As long as we are not capable of correctly defining what overload is, we will continue to swim blindly in environments of unresolved complaints.
2. Increased management autonomy. A global definition of overload must be complemented by the one applied by each team and allow corrective measures at this level. 
3. Take corrective and reinforcement measures in the centres with the highest overloads. The detection of overloads must always be associated with corrective measures that modify the structure, staff, organisation and/or management of the centre concerned.
4. Stop doing what is inefficient to do what is necessary. Rethink routines of follow-up and excessive control of patients at risk or with chronic diseases. De-bureaucratize. Rethink the electronic medical record system based on clicks to comply with institutional control criteria.
5. Adequate funding to cover absences. Maintaining undersized templates is one of the roots of the health overload problem. Taking into account the peaks in attendance due to winter epidemics or staff vacations in summer implies having reinforcement people on the payroll. 
6. Population education measures on the use of the health system. Not every nuisance is susceptible to attention in the health services, but institutional and media support is required to reinforce the advice of health professionals in this respect. 

In order to change the situation, it is essential that all the actors involved become aware of the situation and take synchronised action. Scientific societies, professional associations and trade unions have a determining role but it is necessary that a great majority of professionals assume the red lines of bearable overload and fight so that they are not violated by publicly denouncing the situation before the judicial authority. The management structure should ensure that the overloads detected are quantified and corrected, and that the legal adjustments and economic means necessary to reinforce or improve the overloaded services are demanded at the political level. 

Shall we get going?

@doctorCasado

Link to blog "La consulta del Doctor Casado"