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Why people don’t like doctors – medical practice in a dysfunctional society
Journal of Clinical Forensic Medicine (2002) 9, 193–195 Ó 2002 Published by Elsevier Science Ltd and APS. doi:10.1016/S1353-1131(02)00094-9, available online at http://www.idealibrary.com on
PERSONAL VIEW
Why people donÕt like doctors – medical practice in a dysfunctional society Peter Blake* Otolaryngologist/Head and Neck Surgeon, Wellington, New Zealand Journal of Clinical Forensic Medicine (2002) 9, 193–195
todayÕs society. Indeed, the ‘‘The Dysfunctional Charter’’ might best sum up the values inherent in todayÕs society. It might be said, by the way, that one feature of a ‘‘dysfunctional society’’ is separation of authority from responsibility.
INTRODUCTION Doctors have felt increasingly threatened over the last 25 years. It seems as though the profession has few friends these days. There is constant criticism appearing in the media. Insurance companies and commercial organisations struggle with the rising costs of medical care, increasingly at the doctor and patientsÕ expense. Politicians and health economists want to interfere at every turn in what are regarded as traditional medical activities and our colleagues in the legal profession see us simply as a means of making a living. It is hardly surprising that we feel like a profession under siege. Curiously, and despite the fact that we seem to be in conflict with large and powerful groups in different areas, we have retained a remarkable degree of respect from the public at large. Politicians and journalists, at least as far as New Zealand goes, remain well and truly at the bottom of the ‘‘most respected and trusted professions list’’ in New Zealand. Many of the medical professionÕs problems stem from a direct clash between the values inherent in good medical practice and those (if you can call them ‘‘values’’), which exist in todayÕs society. Doctors traditionally are somewhat authoritarian, cautious, and reactionary as opposed to being proactive. It is the nature of our job. This all sits rather poorly with what might be termed ‘‘the brave New World’’ of
THE DYSFUNCTIONAL CHARTER 1. 2. 3. 4. 5. 6.
7. 8. 9. 10.
There is always someone to blame. It is never you. All rights are reserved to you at all times. Your rights over-ride the rights of others. Those with whom you deal shall constantly exercise care, skill, and judgement on your behalf. The foregoing standards (5) do not apply to you by virtue of your inalienable right to behave as a free human being, without constraint or limitation. You have a moral duty to inform appropriately breaches in respect of (5). The ‘‘facts’’ are as you state them, not as any other party states. The ‘‘facts’’ may be changed by you, as need dictates but cannot be changed by any other party. Telling the ‘‘truth’’ may impose a self-determined duty to lie but no one shall lie to you.
WHO DOES NOT LIKE US 1. 2. 3. 4.
Received 10 May 2002 Accepted 10 July 2002 Peter Blake MA (Oxon.), MBBS (Lond.), FRACS, 6 Upland Road, Kelburn, Wellington, New Zealand.
Some of our patients. Corporates. Politicians. The media.
1. Patients. Patients are not a ‘‘representative cross-section of society’’. Most of you will be aware that there are studies on general practice and hospital
Correspondence to: Peter Blake MA (Oxon.), MBBS (Lond.), FRACS, Tel.: 64-04-475-3727; fax: 64-04-475-3146; E-mail: [email protected] 193
194 Journal of Clinical Forensic Medicine patient populations that show that they are significantly skewed towards patients with psychiatric disorders. In the days when general medical outpatients used to be held, it was often stated that over half the patients attending a general medical outpatient clinic had significant symptoms of depression. An old adage about general practice is that 90% of a GPÕs time is spent dealing with 10% of the practiceÕs patients. It has parallels in hospital practice although the impact is not quite so great. The net result is to produce a population of regular users of medical care who are difficult to please and very quick to complain. It is doubtful whether a commercial retailer selling a standard market-place product would survive very long dealing with a like population of consumers. 2. Corporates. The issue for the corporates is money. The United States never had much of a socially funded health care system. When most Western European social democracies moved towards a state funded health system, the USA moved much more towards a ‘‘privately’’ funded health system – ‘‘insurance’’. This was pushed along strongly by the imposition of wage and price controls imposed after the Second World War as an attempt to control inflation in a booming post war economy. As corporates could not offer their employees increased wages or salaries they offered them other types of ‘‘benefits’’. One of these was ‘‘free’’ health care – the corporate picked up the insurance tab. ‘‘Privately’’ funded became ‘‘corporately’’ funded. While the American economy boomed, corporates were not worried about the bottom line as profits were good. Once North America felt the bite of the Asian ‘‘enterprise economies’’ matters began to change. The accountants started to look at where the money went and ‘‘free’’ health care came under the spotlight. Managed care was born here. A decision was made that the problem was that there were too few doctors trying to treat too many patients. The solution, it was argued, was to radically increase the number of doctors and then drive down their fees. Unfortunately, this simplistic thinking did not take into account two factors. The first was that the demand for medical care was, at least as regards commercial comparisons, near to insatiable; and the second was that each doctor accounted for fixed costs which were not ‘‘peanuts’’ and which have been estimated recently at between $US50,000 and $100,000 a year. A classic example of achieving that which is not intended, the effect of expanding the production of doctors in the United States was the exact opposite of that which the theorists had predicted. Medical costs went through the roof, not through the floor. Relationships between the corporate sector and the medical profession deteriorated.
3. Politicians. For politicians, the issue tends to be power rather than money. Of course, they always say they have no money. The real problem is the decisions they make about spending it. Those decisions are driven by a desire to be re-elected. But, money aside, politicians do not like doctors. They are jealous of the professionÕs autonomy and respect. The political world is a strange one. After a while, politicians become enveloped in an all-obscuring gray mist and through this they are unable to detect difference between fact and fiction, truth and lie, reality and pretence. I cannot comment about politicians in countries other than New Zealand, but in New Zealand they exhibit a marked tendency to wish to control. Many of them only know political life and remain in it for decades on end. They lose touch with the real world. It has been remarked ‘‘Make your MP work – vote him out’’. Forgive the sexism but you get the drift. 4. The media. The media have embraced the culture of blame. They create public opinion in order to further manipulate it, the purpose being to sell copy. They have a marked tendency to romanticise complex issues into the good versus the bad and they are not interested if an issue cannot be dealt with in a 30-s sound byte or a couple of paragraphs in a newspaper. Further, they bleat about the freedom of the press despite the fact that most newspaper editors will push the opinions and political views of their owners or risk losing their job.
HEALTH CARE AND THE DYSFUNCTIONAL SOCIETY Health care, of course, remains an insoluble problem. Runaway costs will bankrupt the country, so the health economists and accountants have predicted. In New Zealand, expenditure on public health has remained at a near fixed percentage of gross domestic product (GDP) for most of the last 20 years – probably somewhere around the 5–6% level, depending on how it is calculated. Private expenditure on health has remained at about 2.5% of GDP. There is little real evidence of a ‘‘blow-out’’ in fiscal terms. The ‘‘blowout’’ has occurred in service delivery, not in dollars spent. What we have witnessed in New Zealand, and elsewhere by all accounts, is the evolution of increasing waiting lists and a technology lag. The solution to the problem is to ‘‘manage’’. In New Zealand, millions have been spent on ‘‘managing’’ health care in the face of an infrastructure which is crumbling away. The point is that we have lost sight of the wood for the trees. We do not seem to see a clear way forward. We are confused. So where do we go from here?
Why people donÕt like doctors 195 If you are a doctor, or for that matter a policeman, stick with your patients, or the public at large. Overall they have offered both the police and doctors excellent support over the years. In New Zealand, despite attacks on the profession from the media and politicians, we managed to claw our way back up the ‘‘most respected occupations’’ list from a previous sixth to third place. All things considered, it is a good result. We need to think about what the terms ‘‘change’’ and ‘‘reform’’ really mean. What is the purpose of change or reform? What are you there for? What are your primary and core values in your job? Money is often the argument that underlies the ‘‘need for change’’. If there is an alleged shortage of money, the inevitable tendency is to blame you for the resultant problems. How much are you responsible for this? How much is due to political decisions about the way money is spent? How much is due to the fact that politicians who wish to stay in office in effect end up buying votes and what you do just is not perceived as being very important? In short, to what extent should you substitute the provision of adequate resources for personal risk and stress? Those who attempt to push doctors into this position need have no fear of liability in regard to the consequences of the change they wish to effect; nor would they be able to meet the very standards they impose on the profession from the moral high ground they so hypocritically occupy.
Western social democracies have been under an increasing economic threat for the last 50 years, from mainly Asian ‘‘enterprise’’ economies. ‘‘Western’’ economies and the cultures of Europe, North America, and Australasia have a strong Judaeo– Christian ethic which has served them as well, if not better, than the alternatives for a good few hundred years at the least. Important features that have evolved are a mutual respect between individual and Society, compassion for the weak but an expectation of work from the able, respect and reward for hard work, achievement and saving; and a strong belief in the power of the intellect, manifest by respect for reason and knowledge, investment in science, and pleasure in the arts. This is not a description of where we are today. Perhaps it is time for reflection, not only on the need for reform and change, but on where we are from and why we have achieved so much.
FURTHER READING 1. Mark Mazower (author) 1998. Dark Continent – EuropeÕs Twentieth-Century, Penguin Books, ISBN 0-14 024159-0. 2. John Ralston Saul (author) 1992. VoltaireÕs Bastards, Penguin Books, ISBN 0-14-015373-X. 3. Jared Diamond (author) 1998. Guns, Germs, and Steel – a Short History of Everybody for the last 13,000 Years. Vintage ISBN 0-09-930278-0. 4. Michael Burleigh (author) 2000. The Third Reich – a New History. Pan Books ISBN 0-330-48757-4.
PERSONAL VIEW
Why people donÕt like doctors – medical practice in a dysfunctional society Peter Blake* Otolaryngologist/Head and Neck Surgeon, Wellington, New Zealand Journal of Clinical Forensic Medicine (2002) 9, 193–195
todayÕs society. Indeed, the ‘‘The Dysfunctional Charter’’ might best sum up the values inherent in todayÕs society. It might be said, by the way, that one feature of a ‘‘dysfunctional society’’ is separation of authority from responsibility.
INTRODUCTION Doctors have felt increasingly threatened over the last 25 years. It seems as though the profession has few friends these days. There is constant criticism appearing in the media. Insurance companies and commercial organisations struggle with the rising costs of medical care, increasingly at the doctor and patientsÕ expense. Politicians and health economists want to interfere at every turn in what are regarded as traditional medical activities and our colleagues in the legal profession see us simply as a means of making a living. It is hardly surprising that we feel like a profession under siege. Curiously, and despite the fact that we seem to be in conflict with large and powerful groups in different areas, we have retained a remarkable degree of respect from the public at large. Politicians and journalists, at least as far as New Zealand goes, remain well and truly at the bottom of the ‘‘most respected and trusted professions list’’ in New Zealand. Many of the medical professionÕs problems stem from a direct clash between the values inherent in good medical practice and those (if you can call them ‘‘values’’), which exist in todayÕs society. Doctors traditionally are somewhat authoritarian, cautious, and reactionary as opposed to being proactive. It is the nature of our job. This all sits rather poorly with what might be termed ‘‘the brave New World’’ of
THE DYSFUNCTIONAL CHARTER 1. 2. 3. 4. 5. 6.
7. 8. 9. 10.
There is always someone to blame. It is never you. All rights are reserved to you at all times. Your rights over-ride the rights of others. Those with whom you deal shall constantly exercise care, skill, and judgement on your behalf. The foregoing standards (5) do not apply to you by virtue of your inalienable right to behave as a free human being, without constraint or limitation. You have a moral duty to inform appropriately breaches in respect of (5). The ‘‘facts’’ are as you state them, not as any other party states. The ‘‘facts’’ may be changed by you, as need dictates but cannot be changed by any other party. Telling the ‘‘truth’’ may impose a self-determined duty to lie but no one shall lie to you.
WHO DOES NOT LIKE US 1. 2. 3. 4.
Received 10 May 2002 Accepted 10 July 2002 Peter Blake MA (Oxon.), MBBS (Lond.), FRACS, 6 Upland Road, Kelburn, Wellington, New Zealand.
Some of our patients. Corporates. Politicians. The media.
1. Patients. Patients are not a ‘‘representative cross-section of society’’. Most of you will be aware that there are studies on general practice and hospital
Correspondence to: Peter Blake MA (Oxon.), MBBS (Lond.), FRACS, Tel.: 64-04-475-3727; fax: 64-04-475-3146; E-mail: [email protected] 193
194 Journal of Clinical Forensic Medicine patient populations that show that they are significantly skewed towards patients with psychiatric disorders. In the days when general medical outpatients used to be held, it was often stated that over half the patients attending a general medical outpatient clinic had significant symptoms of depression. An old adage about general practice is that 90% of a GPÕs time is spent dealing with 10% of the practiceÕs patients. It has parallels in hospital practice although the impact is not quite so great. The net result is to produce a population of regular users of medical care who are difficult to please and very quick to complain. It is doubtful whether a commercial retailer selling a standard market-place product would survive very long dealing with a like population of consumers. 2. Corporates. The issue for the corporates is money. The United States never had much of a socially funded health care system. When most Western European social democracies moved towards a state funded health system, the USA moved much more towards a ‘‘privately’’ funded health system – ‘‘insurance’’. This was pushed along strongly by the imposition of wage and price controls imposed after the Second World War as an attempt to control inflation in a booming post war economy. As corporates could not offer their employees increased wages or salaries they offered them other types of ‘‘benefits’’. One of these was ‘‘free’’ health care – the corporate picked up the insurance tab. ‘‘Privately’’ funded became ‘‘corporately’’ funded. While the American economy boomed, corporates were not worried about the bottom line as profits were good. Once North America felt the bite of the Asian ‘‘enterprise economies’’ matters began to change. The accountants started to look at where the money went and ‘‘free’’ health care came under the spotlight. Managed care was born here. A decision was made that the problem was that there were too few doctors trying to treat too many patients. The solution, it was argued, was to radically increase the number of doctors and then drive down their fees. Unfortunately, this simplistic thinking did not take into account two factors. The first was that the demand for medical care was, at least as regards commercial comparisons, near to insatiable; and the second was that each doctor accounted for fixed costs which were not ‘‘peanuts’’ and which have been estimated recently at between $US50,000 and $100,000 a year. A classic example of achieving that which is not intended, the effect of expanding the production of doctors in the United States was the exact opposite of that which the theorists had predicted. Medical costs went through the roof, not through the floor. Relationships between the corporate sector and the medical profession deteriorated.
3. Politicians. For politicians, the issue tends to be power rather than money. Of course, they always say they have no money. The real problem is the decisions they make about spending it. Those decisions are driven by a desire to be re-elected. But, money aside, politicians do not like doctors. They are jealous of the professionÕs autonomy and respect. The political world is a strange one. After a while, politicians become enveloped in an all-obscuring gray mist and through this they are unable to detect difference between fact and fiction, truth and lie, reality and pretence. I cannot comment about politicians in countries other than New Zealand, but in New Zealand they exhibit a marked tendency to wish to control. Many of them only know political life and remain in it for decades on end. They lose touch with the real world. It has been remarked ‘‘Make your MP work – vote him out’’. Forgive the sexism but you get the drift. 4. The media. The media have embraced the culture of blame. They create public opinion in order to further manipulate it, the purpose being to sell copy. They have a marked tendency to romanticise complex issues into the good versus the bad and they are not interested if an issue cannot be dealt with in a 30-s sound byte or a couple of paragraphs in a newspaper. Further, they bleat about the freedom of the press despite the fact that most newspaper editors will push the opinions and political views of their owners or risk losing their job.
HEALTH CARE AND THE DYSFUNCTIONAL SOCIETY Health care, of course, remains an insoluble problem. Runaway costs will bankrupt the country, so the health economists and accountants have predicted. In New Zealand, expenditure on public health has remained at a near fixed percentage of gross domestic product (GDP) for most of the last 20 years – probably somewhere around the 5–6% level, depending on how it is calculated. Private expenditure on health has remained at about 2.5% of GDP. There is little real evidence of a ‘‘blow-out’’ in fiscal terms. The ‘‘blowout’’ has occurred in service delivery, not in dollars spent. What we have witnessed in New Zealand, and elsewhere by all accounts, is the evolution of increasing waiting lists and a technology lag. The solution to the problem is to ‘‘manage’’. In New Zealand, millions have been spent on ‘‘managing’’ health care in the face of an infrastructure which is crumbling away. The point is that we have lost sight of the wood for the trees. We do not seem to see a clear way forward. We are confused. So where do we go from here?
Why people donÕt like doctors 195 If you are a doctor, or for that matter a policeman, stick with your patients, or the public at large. Overall they have offered both the police and doctors excellent support over the years. In New Zealand, despite attacks on the profession from the media and politicians, we managed to claw our way back up the ‘‘most respected occupations’’ list from a previous sixth to third place. All things considered, it is a good result. We need to think about what the terms ‘‘change’’ and ‘‘reform’’ really mean. What is the purpose of change or reform? What are you there for? What are your primary and core values in your job? Money is often the argument that underlies the ‘‘need for change’’. If there is an alleged shortage of money, the inevitable tendency is to blame you for the resultant problems. How much are you responsible for this? How much is due to political decisions about the way money is spent? How much is due to the fact that politicians who wish to stay in office in effect end up buying votes and what you do just is not perceived as being very important? In short, to what extent should you substitute the provision of adequate resources for personal risk and stress? Those who attempt to push doctors into this position need have no fear of liability in regard to the consequences of the change they wish to effect; nor would they be able to meet the very standards they impose on the profession from the moral high ground they so hypocritically occupy.
Western social democracies have been under an increasing economic threat for the last 50 years, from mainly Asian ‘‘enterprise’’ economies. ‘‘Western’’ economies and the cultures of Europe, North America, and Australasia have a strong Judaeo– Christian ethic which has served them as well, if not better, than the alternatives for a good few hundred years at the least. Important features that have evolved are a mutual respect between individual and Society, compassion for the weak but an expectation of work from the able, respect and reward for hard work, achievement and saving; and a strong belief in the power of the intellect, manifest by respect for reason and knowledge, investment in science, and pleasure in the arts. This is not a description of where we are today. Perhaps it is time for reflection, not only on the need for reform and change, but on where we are from and why we have achieved so much.
FURTHER READING 1. Mark Mazower (author) 1998. Dark Continent – EuropeÕs Twentieth-Century, Penguin Books, ISBN 0-14 024159-0. 2. John Ralston Saul (author) 1992. VoltaireÕs Bastards, Penguin Books, ISBN 0-14-015373-X. 3. Jared Diamond (author) 1998. Guns, Germs, and Steel – a Short History of Everybody for the last 13,000 Years. Vintage ISBN 0-09-930278-0. 4. Michael Burleigh (author) 2000. The Third Reich – a New History. Pan Books ISBN 0-330-48757-4.