Sometimes, you need the people out front wearing the black hat. Besides, I think it suits me.
There’s been plenty of celebration around, championing the benefits of change in the healthcare sector, but little recognition of what we have lost.
I recognise that I am coming to the end of my career, and so I will have the tendency to view the old days with somewhat rose-coloured glasses, but I do prefer them to the charcoal-coloured set I tend to use at the moment, so here goes.
Continuity
It goes without saying really. There are people who walk down my corridor and I know they are unwell because I know them.
They have invested heavily in what Balint used to call the trust fund, a mutual investment we both make that allows us to transcend shameful things: their embarrassment, my mistakes, to continue a therapeutic relationship that matters.
A team does not have that relationship. It cannot. It might relate to one part of a person – their cancer, their role as a carer, but it does not relate over long period of time, and this is a loss
Trust
I am exhausted and demoralised by the microregulation of my profession.
It seems that everyone from the economics to the Board sincerely believe the positivist assumption that you can know the whole if you split it up into ever smaller parts and manage each one individually.
If you look at the Code of Conduct closely, I think you would have to be a combination of Hippocrates, Florence Nightingale and Superman to meet the lot, and that would be doubtful.
How on earth can a junior doctor “ensure they work safe hours”? How can I be “honest AND respectful” when I see another discipline practicing unsafely?
We all know where THAT ends up.
And don’t get me started on education. You can say what you like about doctors, but it beggars belief that anyone thinks we are incapable of choosing how to learn. Goodness knows, we’ve had plenty of practice.
The chair of the Medical Board justified the introduction of audits by telling us she thought we’d be grateful knowing whether we were “up to scratch”.
While that might work in her discipline of clinical pharmacology, it doesn’t work in mine. I would be only too happy to learn if I’m “up to scratch” in the chaos of my consulting room if she is willing to define what “scratch” is.
Respect
I am so done with GP bashing, and I’ve been trying to work out what is going on.
I know it’s a grab for power, from many agencies. I know there is plenty of political point scoring to be had opening something shiny, but I do wonder if it’s more that that.
Are we, in fact, the equivalent of the veterans, shunned when we returned from a brutal war, and the world, well, moved on and would appreciate it if we just got out of the way?
Or is it simply commercial interests, doing what capitalism does and trying to grab a share of the market?
Or perhaps it’s all about the data. In a time where we may well be moving away from capitalism into a sort of techno-feudalism, perhaps it is our humanity that stands against us?
Perhaps health is simply being turned into algorithm-led delivery of products.
Scientific rigour
Let’s be honest. “Evidence-based” healthcare as a concept is dying.
It is being used as an approving bumper sticker after a brief nod to science, but not a lot of rigour.
A colleague calls healthcare research at the moment “policy-based evidence-making” and I couldn’t agree more.
I looked into the dermatology pharmacy trials recently which are registered on the Australian Clinical Trials website, and went down a bit of a rabbit hole. There seems to be no participant information sheets or consent forms (except financial ones). The outcomes are about access, and whether the symptom went away after 7-10 days, which, of course, says nothing about whether the diagnosis was correct.
The model of care was implemented nationally before the results were available. I think I’d call that marketing, not a “trial”.
Ethics
Conflicts of interestare getting muddier by the day.
I’m old enough to remember the oxycontin debacle. For the many doctors who are not, the shame of it was the doctors who were complicit in taking up pharmaceutical company sponsorship to advertise the drug as safe and non-addictive.
After that there was a huge push to remove all drug company branding from our offices, including, unfortunately, the best piece of branding ever, Puff, the purple Seretide dragon.
However, there has been no discussion that has not been quickly shut down from governments and guilds about the conflicts of pharmacies selling what they prescribe.
Ninety-eight percent of the women in the UTI trials were given antibiotics. This is not a win, and may be part of the reason we now have trimethoprim resistance.
We, and the women involved, have no idea what the prescribing pharmacists earned from each interaction. I can’t find a breakdown anywhere, but it must be significant, or it wouldn’t be one of the pillars of financial sustainability in the industry.
Every time this question is asked, it is reframed as a “turf war”. This is not surprising, coming as it does from the most anti-competitive industry in the country, but it’s wrong.
It is an ethical question. People have the right to know that the service they get from a pharmacist is or is not subsidised by the government and /or the pharmaceutical companies.
They also have a right to know that when their “UTI” is managed at a pharmacy, it is a different service to the nurse-led clinic or the GP. The three Boards will not expect the same standard of care, I suspect.
The public have a right to know this.
Equity
Complex health systems are impossible to navigate if you can’t read. Or if you can’t use a computer. Or if you don’t have one.
Those are the people we are supposed to serve.
Related
Holistic care
I am not being touchy-feely about this. Treating by algorithm is reductionist. What does this mean?
I mean it’s as dumb as saying we will fix climate change if we use an army of biochemists.
In the 1950s (!) good old Balint talked about the collusion of anonymity, the person going round a spiral of super-specialists and nobody taking responsibility for the whole person.
We are at it again as a community. It doesn’t work, it never worked, and if multidisciplinary care involves the sort of communication it needs to make sure everyone is on the same page, it is unlikely to be anywhere near as cheap as we are.
We know this. We have seen it in the NHS. Do we really need to replicate a failure?
I know nobody ever wants to see the Negative Nelly, the doomsayer, the person like me who talks about the good ol’ days, but really, someone needs to.
In the US, one of the great unsung medical heroes is someone I doubt you’ve heard of. She was a Canadian-American pharmacologist, physician and administrator who refused to authorise thalidomide for market because she had concerns about the lack of evidence regarding the drug’s safety.
She could only withhold approval for 60 days at a time, so she kept asking for the clinical trial information every 60 days, until it became obvious that thalidomide was a bad idea.
Sometimes, you need the people out front wearing the black hat. Besides, I think it suits me.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
