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8 Comments

  1. 1

    Murf

    Contrary to your stance on doctors and knowledge of resource use, I would be very happy if my doctor had the economic consequences of treatment at the back of her mind! Although I am only a student of public health at the moment I can see that all the small decisions by individual doctors can have a huge effect on particular sectors of the health budget – the biggest chunk in Australia’s federal budget. There are formulae for estimating the relative efficiency and opportunity costs of various actions [see http://www.appliedeconomics.com.au/pubs/papers/pa03_health.htm%5D, so that individual value judgments are not forced to surface and to genuinely guide decision-making. Although I find some of the conventional “values” unpalatable, their application would allow at least hospital funding to go to the patients [& their doctors] most likely to get the most life “mileage”. At the moment we have some groups of surgeons and physicians who are “fans” of particular treatments which aren’t necessarily based on outcomes or economic equity for patients. For example, a group of cardiac surgeons at a hospital develop a [expensive] technique which they find can save very old patients from death or major disability, so they use it more. By applying their expertise and the hospital’s resources in this way they are depriving middle-aged patients of an equally good procedure which would give these guys a much better pay-off in length and quality of life. The real crunch comes when you try to persuade a cardiac surgeon to become a “champion” for the procedure on the younger men vs. the old guys. I’d like to see the economic considerations play far more of a role in medical decision-making than they do currently, but IN THE BACKGROUND. Individual patients shouldn’t have to argue their cases.

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  2. 2

    ihaywood

    It’s true top-level ‘macro’ funding resources require balancing different sectors and doctors aren’t particularly good at that, everyone wants to advocate for their own sector.
    But the reverse is true: bureaucrats are very bad at ‘micro’ decisions around clinical care of individual patients, unfortunately this doesn’t seem inhibit them.

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  3. 3

    Andrew Pesce

    Thanks Gavin, this is a very articulate presentation of your perspective. Now perhaps I might put mine.

    You refer to an unbearable burden of responsibility that doctors are asking for when lobbying strongly for a role in participation in the management decision making processes in the hospitals where they work. I agree that it is a heavy burden we are contemplating but I can suggest some existing ones which are even heavier.

    It is the burden of a doctor given the responsibility to care for his/her patients, but with no authority to make any real decision in the hospital processes which control his/her ability to deliver that care.

    It is the burden of doctors being told they must implement decisions made by people they have never met, who have never been seen in the departments, wards and clinics where they care for their patients. Those people who – by the way, Gavin – have no more training in the ethics of equitable use of health care resources than doctors, and certainly don’t have the direct experience to appreciate the immediate let alone distant consequences of their decisions. They certainly aren’t any more likely than doctors to objectively assess the efficiency of closing outpatient clinics or cutting hospital operating lists whist employing more administrative staff not directly involved in patient care.

    It is the burden of internal conflict visited upon complex organisations, where those who actually have to deliver the services are excluded from governance structures, and who consequently are more likely to undermine attempts to impose top down decisions rather than, by having some sense of input and ownership of those decisions, commit to implementing them.

    The AMA has not said doctors should make the decisions in hospitals by themselves. It acknowledges the need for managers and financial officers to impose necessary disciplines on our hospitals. But the corporate and clinical governance structures MUST have hard wired mechanisms for doctors, nurses and other health professionals providing the clinical care in our hospitals to also have real input into their hospitals’ decision making processes. Lead Clinician Groups offer an opportunity not for doctors to control the hospitals, but for them to take their rightful place at the decision making table from which they have been increasingly excluded to the detriment of the public hospital system.

    Only then might all of us who are committed to public hospital care contribute to the challenges we must face of providing equitable access to quality care for all Australians, other than by just turning up to work.

    Andrew Pesce
    President, Australian Medical Association

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  4. 4

    rhwombat

    Well put, Andrew.

    It’s a little hard to accept generalised accusations of incompetence in ethics or understanding on the part of we clinicians (many of whom are not only capable of understanding the finer points of both, but have spent a working lifetime implementing them) from a member of a craft group (economics) with a somewhat chequered history of the same qualities (the group, not the member). We don’t just look after one patient (despite Gavin Mooney’s fantasy of being the the sole focus of our skills) – we (and, in the Public Hospital System, it is always several clinicians working together, never a single unsupported person) look after many, simultaneously: how is that different from having the knowledge, skills and compassion to see where we should put our collective efforts across several overlapping systems?

    To reverse the charge, what gives a non-clinical Health Economist the right to exclude the clinicians from the process? Gavin Mooney seems to argue for exclusion of those of us who are ready, willing and (perhaps, disconcertingly) able to get involved in more than the individual patient in front of us. I know it is disconcerting for an economist to consider values and benefits other than the financial, but it probably behoves a member of one craft group not to disparage the input of others who have always had a large stake in the equitable and efficient delivery of health care in hospitals with full cognisance of their competency and ethical concerns. I’m reminded of the Monty Python skit (written, BTW by Graham Chapman MBBCh) about the machine that goes Ping!, and plaintive question of “what do I do?” from the patient in labour. The response (from Chapman) was: “Nothing, dear – you’re not qualified!”. Ping.

    Richard Lawrence MBBS PhD FRACP.

    Reply
  5. 5

    Gavin Mooney

    Thanks Andrew for your very full, reasoned and eloquent response. Three things. First I believe these issues need to be debated much more than they currently are. By implication you would seem to agree. Second the fact that the AMA National President is willing to debate them (semi) publicly on Croakey is delightful. We need more voices to enter this debate however.
    Lastly I did not mean to imply (and I certainly do not believe) that doctors should be excluded from either valuing or deciding. But the issue for me remains: with respect to what? So the questions of ‘whose values on what?’ and ‘who is to decide on what?’ need more debate – and resolution.

    PS to Dr Lawrence
    First can I gently ask you please to read what I wrote? Secondly you might like to take a leaf out of Dr Pesce’s book in how – in a reasoned and eloquent way – to debate such issues.

    Reply
  6. 6

    Andrew Pesce

    Thanks Gavin. I also wonder whether you have read the AMA submission to the DOHA consultation paper on Lead Clinician Groups(LCGs) or are commenting on media reports. Our submission can be found at
    http://ama.com.au/node/6424
    You will see there that our view is not that doctors assume a management role, rather to incorporate a meaningful role in the governance structures for doctors and other health professionals. It specifically suggests that LCGs will provide advice to hospital management and Local Governing Councils. After consideration, that advice may be accepted or not accepted, and the whole process should be made available to the public and hospital staff by appropriate communication including the LHN intranet and public website.
    I hope you and other readers will appreciate this is a considered attempt to redress the imbalances I referred to in my original response to your paper

    Andrew Pesce

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  7. 7

    rhwombat

    Professor Mooney,

    Thank you for taking the time to post on this topic, and to respond to comments. I did indeed read what you wrote, together with Andrew’s eloquent (and I suspect unexpected) reply, which prompted me to respond, publicly and identifiably (which is not without risk), because your post seemed (perhaps intentionally) provocative – in a public forum with the capacity for feedback. What I take from your initial post is that you object to Andrew’s public comments on the proposed membership of Lead Clinician Groups, on the grounds that clinicians lack appropriate training, competence or judgement in community values, the “definition” and determination of efficiency and equity, and ultimately, the ethics of allocation of limited clinical resources. To quote: “Yet asking medical clinicians – as Dr Pesce seemingly wants – to be involved in advising not just on effectiveness of care but ‘efficient and equitable use of hospital resources’ is, I would submit, putting them in this ethically invidious and untenable position”. You seem to me to argue fairly vehemently for exclusion of clinicians from resource allocation decisions because they are not health economists. In your response to Andrew’s reply you seem to repudiate yourself fairly comprehensively. You are less gracious in your response to my “voice entering the debate”.

    Despite your claim about not wanting to get into a “turf war between different clinical groups” (…by which I suspect you mean professional, as in economists vs clinicians), the bones of your comments seem to be just that: we clinicians should keep out of what you see as your turf – value, efficiency, equity and ethics, because we are not trained for it. Furthermore, you see some ethical dilemma in clinicians being involved. On the contrary, I suspect that most of us who practice in hospitals (or other large cooperative health care organisations) have far more grounding and experience in these areas than the average economist. I wasn’t aware of Ethics and Public Health (including specific teaching in Statistics and Health Economics) being essential subjects for a degree in Economics: they are for Medicine. Ongoing, reflective professional education (including ethics) is mandatory for clinicians: I’m not aware of that being the case for economists. Many of us have been active in professional bodies (like the RACP and AMA) with specific resource allocation perspectives at local, state and national levels for many years. Decisions about resource allocation and access to limited resources are our daily experience, and we get quite good at it: Who gets theatre time, and for what? Are we going to dialyse this 41 year old “developmentally delayed” woman with diabetes? How can we help the 190kg diabetic with respiratory failure? Can we circumvent the 10 week “queue” for chemotherapy for this 39 year woman with 2 young kids and lung cancer – and which service are we going to defund to get the chemotherapy waiting time below 10 weeks? These are real situations, involving real people, and we clinicians make similar decisions with profound consequences daily, without the benefit of a health economist’s lordly objectivity.

    In fact I suspect that the issue of objectivity is the elephant in the room here. Perhaps you really do think that acting as a remote and unapproachable authority, capable of stark, impartial utilitarianism, on whom can be blamed the economically unimpeachable decision to withhold limited resource, thus sparing the noble clinician and (probably more importantly) the bureaucrats and politicians who may have to face public blowback. In reality, we clinicians have to communicate those decisions to the individual patient (or consumer if we are to keep to econospeak) anyway, and, as pointed out, have well developed ways of doing so.

    The other end of the elephant is the tradition of domineering clinicians (particularly, but not exclusively, from some of the surgical tribes), who obstinately insist that what’s good for them must be good for everybody. We acknowledge (and, usually, try to avoid being) them, but have also had more experience in effectively dealing with such beasts on a personal level than your average bureaucrat (or health economist). Granted that we clinicians must prove that we are not wreckers, but please also acknowledge that resource allocation is a political as well as a quasi-rational process.

    In summary, to reject the interest and experience of clinicians offering to try to help resolve some of the thorny issues of health budget allocation on the grounds of saving us from ourselves seems to me both churlish and counterproductive. Is that “reasoned and eloquent” enough debate for you?

    Richard Lawrence

    Reply
  8. 8

    ianhargreaves

    One thing clinicians have to do is explain complex issues to people from all walks of life.

    Take this simple analogy. Prof Mooney, due to your economic expertise in making value judgements about equity, efficiency, and effectiveness, you are appointed to the Australian Astronomical Review Board, to allocate funding for our new federal telescope.

    Astronomers are like doctors – each a professional with fervently-held beliefs and opinions.

    The Board asks astronomers to advise and give technical judgements on effectiveness.

    One group insists on Cassegrain optics. One group prefers Coude. Some advise a single telescope of maximum size to see further, but others see wisdom in getting two smaller telescopes to observe two areas simultaneously. One submission says the money would be better spent on a radio-telescope for quasar studies, while another advocates not building anything, but using the budget to buy time on the Hubble telescope.

    The Australian Astronomical Association president Dr Escep says: “Specifically, astronomers should be involved in decision-making about funding for infrastructure, staffing and training within their observatory to ensure it is allocated efficiently and equitably.”

    Now, place your hand over your heart, (and your other hand over your styloid process) and say that you want no involvement from astronomers: “Yet asking astronomers – as Dr Escep seemingly wants – to be involved in advising not just on effectiveness of observation but ‘efficient and equitable use of observatory resources’ is, I would submit, putting them in this ethically invidious and untenable position.”

    Furthermore, your preference would be, as I understand it from the article, to have no astronomer on the Board itself.

    To put it another way, you would recommend the spending of millions (or billions) of dollars of taxpayers’ money to buy equipment and employ professionals, and not one person on the board making the decision has ever personally used any comparable equipment, or has any personal experience in understanding the arcane terminology used in the professional submissions. How will you find NGC 1301, or even your own styloid process?

    The real answer lies hidden in your original post: “It is a social value judgment.”

    The people most skilled at judging would probably be neither economists nor clinicians, but judges. There is already an Equity Division of the NSW Supreme Court, and it would be preferable for a judge to take submissions from all parties, then make a judgement based on the laws made by the people’s elected representatives. The process could be simpler if inquisitorial rather than adversarial.

    Politicians may well campaign on specific health issues – funding for the Royal Hobart Hospital cost the ALP its majority at the last election – and pass specific enabling legislation, eg the UK government legislated specifically on waiting times for outpatient visits and treatment. This allows more transparency as I can think of no better individual or committee than the electorate as a whole, and the elected MPs, to prioritize hip replacements or heart transplants. An experienced equity judge would resolve the inevitable conflicts.

    The salary of a judge is trivial compared to the cost of a non-clinician committee’s buying a CT scanner that doesn’t work because it is cheaper (my hospital did that), or designing a new building without access to wheel a bed to the old building, to get to the X-Ray department or a lecture theatre (two of my hospitals did that).

    Alternatively, if the frugal NSW government wants to save money, your post alludes to a cheaper yet equally satisfactory option. In demonstrating how easy it is to make complex value judgements, for even ordinary people who juggle work and family lives without formal ethics or economics training, consider Dr Chua’s workday.

    As he arrives at his surgery, his motherly receptionist says: “Mr Smith thinks he may have another melanoma, so I’ve squeezed him in for 2:45. Mr Artells is worried his wife may be suicidal.” Dr Chua nods gravely: “And who’s that on the phone?” “An economist with a prostate problem – I’ll book him for Thursday week. Here’s your bag and the Artells’ address. I’ll have a strong coffee and a full but placated waiting room for you when you get back.”

    $30 an hour.

    Employ that mother.

    Reply

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