Altruism and fear can be beaten out of anyone, and what is left is a shadow of the masterful profession they leave behind.
I grew up in an industrial city, with a family full of tradies and engineers.
In my childhood, there were men’s sheds, full of handy bits and pieces: rusting bits of cars, a huge variety of tools hanging on a pinboard, and crucially, Vegemite jars with their lids nailed to a handy “4×2” length of wood.
In those jars, men (and they were almost universally men) kept nuts, bolts, screws and so on, labelled in metric and/or imperial measurements. There was always a jar labelled something like “screws, miscellaneous” and, of course, the ubiquitous fencing wire and duct tape.
Engineers had a lot of choice and control in those days. Of course, they had budgets, but this didn’t seem to preclude overdesign. If they thought something ought to be made double its strength and weight, just to be sure it coped with the slings and arrows of fortune, it was.
I often wonder what those engineers would have thought of our current situation.
Like engineering, medicine is also a profession. One of the features of a profession is autonomy and the ability to self-regulate.
In the past, we decided how to allocate not only our own budgets, but the budget of the community. Gatekeeping wasn’t hoarding resources like a dragon on a pile of gold, it was about preserving communal goods.
We could say no to the mother of a child with a viral URTI, knowing that she would return if things got worse. In that way, we kept the power of antibiotics for the people at highest risk: the very old, the very young and the immunosuppressed.
Using the engineering analogy, if we needed to invest more communal resources in a particular case, we did.
If we failed to manage someone appropriately, we were accountable to our professional body, who would consider whether we had shown a “flagrant” disregard for acceptable standards. In this way, regulation accepted that the person in remote practice may well use a hand-held drill to make a burr hole because, on the balance of probabilities, this was the safest thing to do.
Those boards would, of course, not accept this behaviour in a tertiary hospital.
One of the biggest reasons I feel demoralised at present is the lack of this autonomy. I am no longer in control of budgets. I’m also not in control of resources. And so, I often have little control over poor outcomes, but I am held responsible for disappointing the masses.
Frankly, governments advertise gold-standard services, but give me a base-metal budget to achieve them.
In my view, this is how it works.
Governments decide the budget
And they do it without reference to our needs. They also decide what we are to do with it.
Using the analogy of engineering, they are asking us to build a series of complex buildings, having outsourced the easy ones to others with a far more substantial budget.
We are doing more complexity with less funding.
Governments supply us with resources
This includes architects, surveyors and other experts. This has been severely limited.
We are now making do with duct tape, plastic parts and no access to tradesmen or architects.
Government stewards come to the site regularly to monitor how we use these resources, perusing the skips and making sure we are using every last scrap of plastic we are given.
We are told we should be grateful for all of it, even the bits we have no idea how to utilise.
Governments have taken over regulation
It may not be known by everyone but AHPRA is now overseen by governments. So, the specifications of our buildings are … optimistic. Many would say they are impossible.
We are no longer just expected to meet concrete requirements. We now have endlessly elastic statements like “being open to constructive feedback” or “being fair to colleagues”.
This is not a standard, it’s an aspiration. It is easily weaponised by anyone who isn’t happy with their outcome. Dissatisfied “consumers” are much more likely to report us now expectations are enormous and resources are few.
I don’t blame them. They’ve been promised the Opera House, and they get something that looks like a barn … that may easily fall over.
Governments use the ‘carrot’ of compassion
When we explain that we cannot build the Taj Mahal with plastic, a few nails and a group of tradies, they rely on our compassion and aspirations to fill the gap. “But you want the best for your community, don’t you?” they say. “Will you be proud of this outcome?”
This is known as the “compassion tax”, the way we tend to rise to meet the challenge because we cannot bear to think about something falling over or someone missing out.
Because we care, and because we are perfectionistic, we fill the gaps with volunteer labour and cobble together necessary materials from our shed. Unfortunately, our sheds are emptying rapidly.
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We fill the brief (just) but it’s not enough
A building cobbled together never looks good. It never did. The house I grew up in was designed by an engineer. It did the job. It provided shelter and it stayed standing, but nobody in their right mind would have described it as attractive.
There will always be complaints about the lack of specialist skills we possess. “There are architects available,” disgruntled consumers will assert. “The government says there are plenty of them, so why didn’t they use them?”
The fact that these architects are 500km away in another state, charge a fortune and have no desire to assist in this particular building is insufficient defence.
Governments use the ‘stick’ of regulatory fear
Because we know we are likely to have a disgruntled consumer, we act in fear. AHPRA harms us. Whether it should or not is irrelevant.
Take a group of highly perfectionistic, anxious GPs and imply they are not “up to scratch” and then spend more than a year deliberating whether to discipline them, and we will suffer. A lot.
So, we desperately try to get our plastic building to look somewhat like the Louvre the consumer was promised.
Governments rely on this fear. They have the opportunity to set an impossible budget on the one hand through Medicare, and set impossible expectations on the other with AHPRA.
I call this the “regulatory tax”. The endless donated hours of time we give to ensure this rickety building stays up.
There is a necessary balance with professional autonomy and regulation.
On the one hand, too much autonomy creates an opportunity for bad professionals to do bad things. The bottom 5% of the profession may well behave badly and hurt people without sufficient regulation. This should be why regulation exists; to sort them out and get rid of the ones who exploit their professional power to profiteer, leaving damaged patients in their wake.
However, if professional autonomy is curtailed too much, the innovators, experts and masters have no flexibility and no capacity to do what they know to be right.
In engineering terms, this means the professionals building in difficult environments (like on the edges of cliffs, or in the marshes) will be told they have to use prefab buildings, even when it is clear these rickety structures will fall over in the slightest breeze.
Perfectionistic people do not cope well with this. They have a well-deserved reputation to uphold. They don’t welcome seeing it collapse.
An impossible budget doesn’t get managed with compassion tax and regulatory threat. Altruism and fear can be beaten out of anyone, and what is left is a shadow of the masterful profession they leave behind.
We are watching the masters leave at the moment, demoralised by unrealistic expectations. Frankly, it’s a totally predictable consequence of expecting an engineer to behave like a handyman and an award-winning architect at the same time. What a waste.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
