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This page created October 2000 by Michael Wynne
Doctors do not share the same understandings about quality of care as
the marketplace or as patients. This www page expands on the
relationship between doctors, the market, the community and patients
as it effects quality. Doctors are repeatedly criticised for their
failings and undoubtedly some of these criticisms are valid. To what
extent can they be blamed for this?
Samuel may be thinking of the professions rather than the market when he talks of being unresponsive to consumers in regard to quality issues. He clearly sees "quality" in terms of what the consumer wants or demands. This is how the market thinks. Health care professions see "quality" in a rather different way. This confusion arises because quality is an imprecise word and has different meanings for different people in different situations. Standards is a better word as it requires that the content, parameters, and limits of applicability in each context be defined. The latter word is more threatening and is seldom if ever used in the marketplace.
I partly agree with Samuel but do not think that it is a valid criticism? It is easy to see why the market has failed. We can readily identify profit, competitive pressures and the lack of power of the consumer as the reasons why the market in health care has failed citizens and the community. We need to look at why professionalism has failed or apparently failed to respond to consumers.
The profession has a much broader social
responsibility than simply to meet market or consumer expectations.
Its responsibility is to detect serious disease, treat serious
disease, discover the causes of serious disease and whenever possible
prevent serious disease. If people thought about it the most
important thing they possess is their lives, their physical and
mental well being. The professions prime concern in its interaction
with the public is to pick out those cases where there are serious
problems and something can be done or needs to be done. Every
doctor's fear is that she will miss something and that someone who
has placed their trust in her will die as a result. This is not to
suggest doctors be rude, unsympathetic or non responsive to the
wishes of the patient who will still be given final choice and
responsibility.
The hard reality of medicine and the retrospectoscope is that missing diagnoses which would have saved a life will happen not once but a number of times in the career of each doctor. This will be associated with feelings of guilt and sometimes blame by the patient. Medicine is not yet an exact science and it is easy to look back and say "of course". Each doctor is ethically required to confront this honestly, personally and before colleagues in an attempt to keep these situations to an absolute minimum. This to them is the real face of medicine
I am naive enough to believe that when you
have established an honest relationship you can do exactly this with
the patient as well. You can talk about the decisions and where you
went wrong. I have never been sued for doing so, but have been
threatened when I have been unable to do so. Behind my idea of an
integrated health service run cooperatively by community and
profession is a belief that this sort of honesty and trust is a far
better basis for building a health system than the marketplace
proposals which seek to "reform" health care by fostering distrust. I
like to think that the community would respond to this.
The vast number of medical encounters are for comparatively minor problems which the public experiences and for them this is the face of health care. Only once or twice in a lifetime will the patient confront a serious threat to his life and sometimes he will not realise that it was. If the treatment is effective the doctor who has correctly made the diagnosis will simply say that the treatment will cure it without creating alarm. She may occasionally have to be very confrontational and upset the patient to get the treatment message across. He will not like having his cherished but unrealistic beliefs overruled and may be unhappy even if cured.
The patient is unaware that the doctor is
more concerned with this wider responsibility for his wellbeing than
in responding to his particular whims and interpretations. From a
marketplace perspective this demotion of market principles is
unpardonable but from a professional perspective the doctor is
meeting her responsibility to the patient and society. This is not to
suggest that she should not be responding to the patient to the best
of her ability, but responding to the demands of the "consumer" may
not be in the "patients" best interests. The patient whose "demand"
is not met may be very angry. It is the professional's responsibility
to accept that anger and the financial impact a disgruntled patient
has on her practice if she is doing so in his best interests.
The corporate director has a prime responsibility to shareholders rather than customers or patients. Many if not most company directors will not allow care considerations to stand in the way of responsibility to share holders. This is clear from the US experience. They do not do it deliberately. They develop explanations which allow them to do so without experiencing discomfort. The corporate director will not tolerate doctors who upset patients by refusing to meet their demands. Unhappy patients don't help the bottom line. These doctors are "disruptive".
The health care professional has a prime responsibility to the patient's ultimate physical and mental welfare and to the welfare of the society which has entrusted her with this responsibility. She will not allow the demands of patients or fashionable public perceptions to override this responsibility.
There are therefore good reasons why the profession does not always respond to the marketplace or the desires of the customer or the public, and why on occasions it should strongly resist these. The response of the profession to managed care in Australia is an excellent example.
Professionalism does have a responsibility to challenge and explain. It should give way when contrary arguments are logical, sound and supported by good evidence. Marketplace medicine is not sound or logical. The evidence presented is derived from areas which are not comparable and the evidence from health care itself is ignored.
Society's desires are not the ultimate
determination of what is desirable. To suggest this is to suggest
that the profession should have acceded to antisemitism in Germany
and to apartheid in South Africa. While it certainly bent to these
forces, much as it has bent to market forces, a hard core of
professional values maintained a constant challenge to the ideologies
which dominated these societies. The professions have provided a hard
core of resistance. They continue to do so in the face of economic
rationalism.
There are other problems which have caused the medical profession to retreat behind a protective laager. I have already mentioned the unprecedented attack on the profession by market advocates and politicians, frustrated by the professions unwillingness to abandon its professional heritage in the face of their demands.
There is another problem and this is the problem of knowledge and expertise. It is simply no longer possible for one doctor to know enough and have enough skills to provide the service each patient requires, yet the patient often expects this and the doctor feels that she is supposed to know. Even a specialist in an area may not recognise or know of a condition with which another is familiar. The doctor's sense of self and the patients confidence place strong pressures on the doctor to be the authority and "know". The consequence of this is that members of the profession are repeatedly found to have failed. Patient's get told one thing, which is then contradicted by someone else. They go on a merry go round. Another doctor or perhaps a practitioner of alternative medicine eventually becomes the hero. The others are labelled as incompetent, and the professions standing is eroded.
This same problem means that pharmacists,
physiotherapists and others are also repeatedly confronted by
perceived deficiencies in members of the medical profession in their
particular area of medical expertise. They become very critical.
Clearly doctors cannot all be well informed about each of these
areas, but it is human to be defensive. At the same time these
paramedical groups do not always see things from a broad perspective.
When these groups try to remedy the deficiencies they see by moving
to offer their services this is seen as a threat and a turf war can
result - particularly when there is strong market competition.
What I have suggested is an integrated system which can bring the various groups out of their defensive laagers to address these problems.
With speech recognition now a reality computer based records are in my view essential. Technology, while it is a long way from replacing doctors does provide a means of screening what is happening and prompting when necessary. It does not replace judgement. The potential to assist clinicians is enormous.
The organisation of care along the lines of clinical services with technological communication threads into each geographic situation would go a long way to addressing these problems. A single GP in a rural town would be a peripheral meeting point and represent all services in her area. She would have access to each service for assistance and each service would be there monitoring to support, prompt, and help her in what is an extremely difficult task. Because the community would be involved in such a system they would have access to and be part of what was happening.
It is clearly wrong for doctors to be
providing services when these can be done equally well and at less
cost by less trained people. I don't have difficulty in the blurring
of roles in a system which can accommodate that and ensure that those
carrying out care are capable, by training or experience. I don't
have difficulties with movement between the health professions. The
new medical courses where nurses and physiotherapists are training as
doctors is a step in the right direction.
Samuel claims that competition will facilitate public information. Experience from the USA shows that competitive pressures discourage the provision of any information which compromises corporate interests, and encourages the provision of information which presents a positive image of the corporate group and is in their business interests. Education is an important vehicle for recruiting patients and is therefore often skewed in the interests of the corporation.
The extent to which corporations will misinform is revealed by the way in which they have used "front organisations" which profess to represent citizens to lobby politicians, market their point of view, and develop a pro-market feeling in the community. Citizens have no idea that what they are seeing on TV or the www is a corporate funded marketing exercise. Citizens accessing one of the largest educational sites on the www are not told that it it owned by the hated Aetna Healthcare.
The way the market informs is well illustrated by the psychiatry books published for public use by Tenet/NME. They were intended to generate a market by increasing anxiety. They were marketed to psychiatric hospitals as "books as hooks" on the basis that by selling these on to families they would secure more psychiatric admissions. I have already mentioned their school fairs and other educational seminars - all very popular in the community.
In 1986 while visiting the USA my wife was spooked by all the publicity about drugs spreading across the world. Much of this probably emanated from the psychiatric corporations. She bought an advertised book. It was written by a psychiatrist, a Dr Gold. Its title and content simply stimulated anxiety and marketed an 800 hot line for help and advice about drugs. It was widely praised in the community and promoted by a number of community groups. Dr Stuckey who died on his boat in New Jersey in 1992 before giving evidence blew the whistle on this doctor. The hot line was one of NME's strategies for persuading unsuspecting and wealthy families all over the USA to fly their teenagers to the highly credible and well advertised Tenet/NME substance abuse hospitals in New Jersey and Florida. Dr Gold and a colleague commuted between them. Dr Stuckey described the care which was actually provided. Both doctors were eventually charged by authorities but I do not know the outcome.
I have already described the "why stop here" marketing by Columbia/HCA, the misinformation by Sun Healthcare and the failure of HMO's to properly inform medicare patients.
I suggest that my proposal for the community
and the profession working together for the benefit of citizens would
provide a vastly superior system of education to one which works for
the benefit of shareholders.
One of the benefits claimed for managed care is its greater focus on preventive medicine. The Australian Consumer Association saw this as one of the benefits and they did not at the time oppose managed care which they called "managed scare". In the USA the market focus was on disease and profit from treating it. Its health service was therefore focussed on treatment rather than prevention. Managed care has it claims addressed this problem, but at the same time it found these preventive health activities a good place to market its policies to healthy people less likely to need them - it helped in cherry picking. HMO's market in health clinics but not in aged care homes or bars where people smoke and drink.
Australian medicine is also accused of paying
too little attention to prevention and this is a valid criticism.
Attempts are being made to address it. I like to think that the sort
of system which I have hinted at as an alternative to the market
would perform much better as a medium for practising preventive
medicine. The involvement of the community would be a big plus.
RELATED PAGES
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CLICK HERE -- to examine the impact of marketplace competition on "quality"
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This page acknowledges that professionalism has failed on a number of occasions and more so recently. It explores the reasons for this and argues that the meaning systems and the values which form the basis for professionalism are sound. Professionalism has failed when confronted by powerful forces which introduce meaning systems which are not congruent with professional values.
CLICK HERE -- to explore professionalism and the market at this level.
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CLICK HERE -- to explore this perspective