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WHAT does the world expect from doctors? Are the expectations of others the same expectations we have of ourselves? Has our training and experience so far equipped us for the world in which we now practice?
These issues cause tension for many of us. We live and practice in a risk-averse and failure-intolerant society – not just in medicine, but generally, and this leads to many paradoxes.
Although the life expectancy and health status of the population are better than ever before, our community seems more scared and dissatisfied with health care than ever.
Deaths from infectious diseases in childhood are now rare – and yet we are more scared of missing a diagnosis of meningitis than ever before. And when a bad outcome does happen, the community rushes to blame, and insists on yet more tests and more processes in a desperate bid to prevent a recurrence.
Part of the problem involves the media. They show the community two extremes – medical miracles and bitter complaints. We are driven to do more, provide more, check more – and then criticised for delivering increasingly expensive health care.
What is even more frustrating is the loss of community trust in our professionalism. Despite decades of working on our communication skills, reducing paternalism and increasing feminisation of the workforce, being a doctor is just not PC.
Ironically, the unquestioning acceptance and respect previously held for doctors has now been transferred to alternative health care practitioners – many of whom provide unproven and expensive therapies to patients who suspend the disbelief they now apply to orthodox medicine.
And yet, it is doctors who are held ultimately responsible for overall health outcomes. We can’t make all the rules, but we are held responsible for their results. Doing your best doesn’t always cut it any more. Ultimately, we are blamed for not being perfect.
Society is pulling us in two different directions. On the one hand, our community wants holistic medicine, delivered with care and time, and with a focus on prevention, chronic care and general wellbeing. When acute symptoms arise, we are expected to swing into instantly accessible acute care, no holds barred and no expenses spared. Risk, people believe, should not just be managed – it should be eliminated.
So what are we to do? There are two areas where we can find our rewards. At the societal level, we can join the growing campaign to cut the complexity of health care – to return to the basic principles, deliver good outcomes with value for money and recognise that the end of life is inevitable.
At a personal level, we can deliver individual care, showing respect for our patients, and emphasising comfort and quality of life.
Posted: 5 July, 2010
Dr Sue Ieraci is a specialist Emergency Physician with 25 years experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. In addition to her emergency department work, Sue runs the health system consultancy SI-napse.
Thank you Sue for a great article that looks beyond the confines of medicine to the broader societal issues that are impacting on the way health is delivered and community expectations are set. My great fear is that the younger group of medical practitioners will adopt the risk averse culture without critique. For this reason I think it important that this topic is raised and discussed more broadly among practitioners and medical educators/teachers make a conscious effort to raise this in teaching/education of junior staff. I look forward to the continuing discussion of this topic in media such as this.
I have come in late on this one.
Sue, though you speak from the highly protected viewpoint of a salaried hospital specialist, you are generally correct.
To put the blame onto the patient is missing the point.
Is it not the Profession that has set itself up like an Aunt Sally row (that betrays my generation!) and that so many of us have set the bar high with exorbitant fees with a likewise exorbitant expectation (recent anecdotes of $300 ENT consultations to $1000 out of pocket fees to the surgeon for a carpal tunnel release come to mind).
Back to reality with sufficient time for explanations of why and why not investigations, why or why not take out the appendix in clear, understandable language, addressing the concerns of our patients can (whilst not necessarily reducing expectations of the quality and nature) clarify the realities and optimise outcomes, and all less expensively.
Yes Sue,
I totally agree. Thank you for making a stand. As a rural emergency doc and clinical educator I am constantly faced with pressures to CT minor head injuries etc. and junior docs whose response is CRP and bloods ad infinitem! When I ask and how will that affect or help your management? often I get a blank look.
Re end of life . This is a major issue especially with Nursing Home patients – we get sooo many sent in the pre-terminal phase or even moribund – Why are NH staff afraid to have people die there?
Then we have pressure on our colleageus to resuscitate and “save” them. I could go on and on.
once again thanks
When/if we suggest people lower their expectations of what Drs can humanely achieve they will feel that we mean we do not trust ourselves. In Pagan Rome, where “Morality” meant consequences and blame, nature was never seen to be at fault when there was a bad outcome. Our legal system and many social expectations still follow that well worn path: somewhere, somehow, some human being is at fault and must be dealt with accordingly. If we suggest that we are only human in the current parlance of reason then we are exposing ourselves to Pagan retribution.
A compelling topic. I agree with the last post regarding high public expectations of medicine. However, none of the comments have included the role of pharmaceutical companies as a promoter of the cure culture and of medicine-mediated panaceas. Perhaps doctors and media need to better communicate risks as well as benefits to redress the balance of patient expectations.
I vigorously agree with Dr Ieraci. I add that one of the issues we need to deal with is the expectations we raise in our patients and their families. When people have diseases that are going to be fatal- and the later stages of these have arrived- we must become far more realistic far earlier and plan to offer patients the best quality of life that can be achieved. Harder to have this conversation than to call the hospital/ICU/retrieval team so someone else can have it after complex, undignified and expensive therapy, but how much better for the patient, their family and the community? Every consult in every medical discipline is an opportunity to educate, whether that be to cure better or to plan for when there is no cure. We need to educate ourselves better to educate the community better, and be prepared to admit that we cannot confer immortality.
Love the comments, but need to elucidate further.
Surely some of the issues lie with the wonders of modern medical dramas. Medical dramas teaches us the following.
1) The patient can die if they are evil. Evil people die. Good people are saved by the miracles of modern medicine.
2) Good people die because of poor doctors. Either the doctor is having an affair with the nurse, or on drugs, or an alcoholic, or depressed.
3) Good doctors don’t make mistakes. Mistakes only happen because of rule #2
4) Modern medicine can save everyone… unless rule #2 or #3 come in to play… or the government refuses to pay for the experimental life saving medication/surgery/prayer… in which case you should go to 60 minutes and tell the world how you ‘Have to’ sell your house in order to pay for said experiment.
On the front line, it is up to doctors, nurses, and health professionals in general to combat these thought processes.
It is unfortunate that the strength of our profession – that of questioning one another in the search of a greater truth – has been interpreted as a lack of competence rather than application of scientific rigour.
One can certainly agree with your tenets that the media promotes “two extremes – medical miracles and bitter complaints. We are driven to do more, provide more, check more – and then criticised for delivering increasingly expensive health care”.
Really, as the media are the primary drivers of these beliefs, surely the best ways to lead the community into seeing the the error in this thinking is to educate the media and the TV series writers. Get more doctors, like Dr Norman Swann from the Health Report, to promulgate a more rational understanding. Have TV series centered around stories where doctors are delivering cost effective care and emphasizing that doctors can’t cure aging and deliver eternal life (as some patient’s families seem to believe).
As a mark of some self respect for myself; from my work as a GP for nigh on 50 years, I have taken comfort from the fact that I am still entrusted to write Death Certificates. This outweighs all of the negatives that have brought the medical profession to its lowpoint in public acclaim of today.
With the realities of economics of today for every household, are we pricing ourselves out of the market? Coupled with this the DIY knowledge offerred electronically will further add to our collective redundancy. Now that is a challenging notion.
Thanks for the feedback. Sure there are rogue practitioners in every profession, but I think the trends that are bloating modern medicine affect almost all of us. Don’t we all recommend extra tests, referrals, treatments under the banner of “not missing anything” when we know deep down that those things do not improve health? In that way, we are teaching the general community that this is what good medicine requires. If we don’t trust our own judgment (the cognitive skills that are unique to our profession), how can we expect anyone else to do so?
To earn the trust of the public we need to be seen to engage with their concerns and proactively monitoring each others performance. If we are not seen to be alert for the rogues and stinkers then they will not trust any of us and we all be seen to be at fault. The public and the media are fascinated by bad news stories. Good news and “the job well done” are seen as boring. This is the fact of life.
We face the same problem priests, teachers and politicians have and it is because a minority so badly let down their profession by dishonesty, greed and deception that in a society intolerant of such excesses we all suffer a shared blame.
It is not so much a problem caused by the media but by a few rogues in our midst. Some of the risk I see is from colleagues acting or practicing without thought and with an arrogance out of touch with modern society. The good doctors soldier on doing what has always been done but their labors are not so obvious.
The other major problem is the universal desire to only provide care for less than 25% of the week. Illness and need for medical care does not cease at 1730 or on Friday afternoon.
I vote for cutting the complexity of health care as you suggest. It’s time for a return to the basics.