Referrals and coordination of care for early menopause

There’s a lot of support needed, and I think the GP has a big role to play because they have often known the patient for a long time and, obviously can coordinate all of these. But I think there is a real need for an additional team to help with that.

Essentially it’s health-coaching with the lifestyle management and prevention of chronic disease. It takes a long time and I enjoy doing it. It needs to be staged and I don’t think that’s ideal. I think that the woman should be able to get as much information as she can on the day but with people coming in for 15 minutes, maybe 30 minutes, it’s sort of barely scratching the surface.

That’s one of the issue, I think, with the general practice. In the general practice place it will be hard, because they will not have that particular time, and it’s important for us, also to have a backup. To have the endocrinologist I can talk to, the gynaecologist I can talk to, the psychologist I can discuss things, you know? And then, a website that they can go through, probably support group, that they can get. Those kind of things. And I think in the normal, general practice, unless you really, specifically or specialising in there, you will not spend your three quarter of an hour to an hour.

I think the GP is the core of it, I have no doubt at all. Sometimes patient ask me, “Can you do indefinite referral?” I keep saying, “I don’t like doing it.” One of the reason is, if somebody sent me a letter with a patient, because at [women’s health clinic] most patients come with a letter from their GP, definitely I will answer it. But two, three, four times down the track, when I don’t necessarily remember to keep reporting it back? So I always like this communication. Even just a short note, to say “I’ll change this thing to that thing, and I’ll see them another year.” It gives me some idea. I think coordinating it, the GP will be the best person to do it, as long as the GP don’t mind doing it, because it’s a lot of work also to do that.

If they’re going to another specialist, if we know, or go through us, we wrote everything, and what has happened, and what is planned, so the others can coordinate with that. That’s probably the best way to do it, I think.

I think the barriers to good care largely are this concept of having to have a scheduled appointment to discuss something about, at a scheduled time. So there needs to be the ability to contact someone at the time that you have the concerns. The way the system works is that you come, you start your treatment, you have your appointments for these treatments, but there has to be some forum that the patient can initiate a contact with an expert, in a timely way.

So this concept that, at the moment the system works that they come for an appointment, eventually we work out that we need, the menopause clinic and we make a referral and four months later they see someone. There needs to be something where actually, you know, “You may think that you need this appointment at this time, please feel free to come and have an appointment.” And I don’t know how you do that in this very, sort of structured rectangular world. It needs to be a bit more fluid and I think that’s a big barrier. And also, they get sick of coming to hospital for appointments and the last place they want to go is the hospital because it’s got a lot of connotations of unhappiness. So, maybe we need kind of almost a community based service for people such as this.

The backbone of communication is letters. The GP writes to me. I write back to the GP. I write – I’ve now gone to typing my own letters – so they can be done on the day and they get sent out on the day. But, we don’t have the right software, so they can’t get emailed on the day; they get posted. So then there can be a delay then.

So they can either be a posted letter or an emailed letter, but it’s formal letter. I do ring GPs in really urgent scenarios but that’s not that common and it’s hard to get that time. There’s no reimbursement for GPs or for specialists to do that. So I think that’s a problem that. For example, other health systems are, reimbursement is based on a time factor and things that are done, not just in the consult, but the time it takes to, say, book a test or other things. It’s not done that way here.

So that makes it hard as well because you can’t ask a GP to book in a slot for, like, 10 minutes to have a discussion with you. So they’ve got to fit it around everything else. But GPs are usually really helpful and all that sort of thing. But you don’t want to waste their time or anything like that. It’s really hard – communication with allied health is often really hard because there’s not that same culture of letter writing. Often there’s a reluctance for people to ring anyway and chat with you. So you often are more like a silo than anything else.

Everything is quite siloed or you’re like all little islands and the patient’s going in a little boat between them all. [laughing] And it’s the patient that’s the common link that tells you everything that’s happened.

You do need to know what’s out there too, and often a psychologist will be very useful. But again then, you need to factor in the GP, because the GP might want to do what’s called a care plan, and then the psychology visits are covered. Because another thing is the cost of all of this, and some women just don’t have the resources to see private specialists and private psychologists.

So again it takes a good amount of thought and consideration, and a lot of careful consideration to get this planned and do it right. And even then for some women it’s not done right, and I think it’s just because this is an overwhelming area, and they didn’t want it. They didn’t want the problem, they don’t usually – some of them don’t want the solution. But most of them are happy to know that someone with expertise is looking after them. I think that’s an important part, whether that’s in a public clinic or a private setting.

There are not many psychologists I think who understand this area, and I know a couple of really good ones, and will always want to refer to them. But again they’re extremely busy and taxed. So it’s hard to get in to those ladies. And the cost thing. So what I will normally do is write a very careful letter, which is a very long letter, when I first see these ladies, and I spend 45 minutes with them. So I make sure I’ve gone absolutely through everything I want at the start.

But it is a several part process. I’ll often suggest “I think this lady would benefit from psychological assessment” and I wonder if the GP who I’m writing to would, if you feel it would be appropriate to formulate a care plan such that this lady could access five psychology visits under this care plan.

And often the GP will just do that. But the GPs are all – because they instigate them, they want to do it in the correct way. And I can’t make one, so they’ve got to do it. So I just suggest it. But that’s all there in their letter, and then that’s a little bit of help. And then if it’s the psychologist that I would want them to see, them hopefully they’re in the area. Because another thing is geography. So it’s no good being out in a rural area, and wanting to see the ladies in town, it’s just not going to happen.

The people who refer to me, refer to our second opinion women’s mental health clinic and really we don’t have any other criteria other than she’s a woman, although we see girls as well. And, often the referral goes something like, “Could you please provide another opinion for the management of depression in this 48-year old woman who has had a trial of two antidepressants and there’s no response.” Full stop. So, it doesn’t actually say, “I think this woman is perimenopausal and therefore depressed. Can you help with an opinion about management in that way?” So, our second opinion starts off with, “We think this is related to menopause. And, while she doesn’t have body symptoms yet, perimenopausal symptoms occur in the brain four to five years earlier, so let’s have a think about using a hormone treatment strategy here.”

That’s very common. Which is a bit sad, because it means that the referring clinician hasn’t got the concept of perimenopause, hasn’t got the concept of hormones and brain and mental state. We’re also getting referrals by “I tried a first line treatment with hormone strategies, but she’s a little better, not completely better, now what?” So, that’s nice.

I am very fortunate because my clinical practise is an interesting model where we have psychiatrists and endocrinologists seeing patients together. So we’ve actually sort of blurred our disciplines. The endocrinologist, [doctor’s name], is very good at taking a psychodynamic history, and I’ve got very used to asking about thyroid and other things. So we’re really very integrated. I really do recommend cross disciplinary work and particularly in a condition like menopause, which has got a whole range of impact.

The holistic approach, I think, is really important. And so we also have an exercise counsellor and healthy eating counsellor. We have a smoking cessation program. We also have sexual health discussions, a whole range.

Psychological help’s not particularly available. In our rural area like this if we have someone who’s having psychological issues with this and we contact the regional triage that they get a phone call from a nurse and the nurse will come and visit them and then make an assessment whether they need to see a doctor.

And then a letter – we’ll get a letter back later. So this people who are well. It’s a slow service. So for those people who are thinking of seeing them privately, they get to see them much quicker and it’s better. But it’s really to have an idea if we can actually focus on which problems they need; whether it’s self-image problems, whether it’s mood, whether it’s anxiety, relationships, all sorts of things.

We have one dietitian for the area. So it’s about a six week wait to get in and that’s okay. And there’s no publicly funded group work for women. So if you want to see a physio it’s one on one. And the [health clinic name] doesn’t do group work. So anything which is like an exercise physiologist getting a training programme, getting core strength up to prevent osteoporosis and falls all those – all those things, it’s one on one.

So I think that in the rural areas we have less resources and people expect to have to pay. So we’re a little bit under-resourced. I think the amount of money that’s spent on health and preventative health and education in rural areas is far less than it is in the cities on a one to one basis. So as I say, we take on many hats and we use resources. I mean, you can’t be an expert in everything and most of our specialist colleagues are very good at providing information over the phone that might help in a one on one situation.

So for example, if it’s post-cancer, in the first instance, the treating doctors who may have provided surgery or chemotherapy or radiotherapy will be intimately involved initially, and less involved as time goes by. And that’s where the family physician becomes most important because he or she is sort of the conductor of the orchestra. I think perhaps gynaecologists, on the whole are not involved in this long term, but will become more involved as they learn more.

Endocrinologists of course would follow through on the bone health and the cardiovascular health as well as general health as time goes by. But I think it will change from time to time and really in my view the most important person should be the family physician who coordinates it all.